Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat Paper

Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat Paper

S.

CC (chief complaint): “I have a runny nose and itchy eyes.”

HPI:

Charlotte is a 28-year-old White female who presents with complaints of running nose and itchy eyes. She mentions that she started experiencing a runny nose, itchy eyes, and ears nine days ago. She also states that she experiences these symptoms every spring, and it usually lasts 6-8 weeks. She states that she has a runny nose with clear nasal secretions and has episodic sneezing the entire day. Her eyes are very itchy, and she feels she want to scratch them. Charlotte further reports having a tickling feeling in her throat and ear fullness, which causes the ears to pop. She reports having taken Claritin last spring, which relieved the symptoms.

Current Medications: None

Allergies: No food or drug allergies. Has seasonal allergies- runny nose and itchy eyes during spring.

PMH: No history of chronic medical illnesses. Had an appendectomy at 23 years.

Immunization: Immunization is up to date. The last Flu shot was nine months ago; the Last Tetanus booster was six years ago.

Soc Hx: Charlotte was born and raised in Queens, NY. She has a Master’s Degree in Finance and is currently a financial consultant working in an insurance firm. She is married and has two children, 3 and 1-year-olds. Her hobbies include canoeing and swimming. She admits to taking alcohol 3-4 glasses of whiskey on weekends. Denies smoking tobacco or using other illicit substances. She reports attending wellness check-ups after 1-2 years. She goes to the gym 3-4 times per week and sleeps about 6 hours per day.

Fam Hx: The maternal grandfather has HTN and Heart failure; The paternal grandfather died from Lung cancer. Her parents and siblings are alive and well. Her children have no chronic illnesses.

ROS:

GENERAL:  Negative for malaise, chills, fever, weight changes, or body weakness.

HEENT:  Eyes: Reports itchy and watery eyes. Denies vision changes. Ears: Reports ear fullness and popping of ears. Denies ear discharge, pain, or hearing loss. Nose: Reports sneezing, runny nose, and clear nasal secretions. Denies nose bleeds. Throat: Reports itchy throat. Denies sore throat or swallowing difficulties.

CARDIOVASCULAR: Negative for edema, neck vein distension, palpitations, chest pressure, or SOB on exertion.

RESPIRATORY:  Negative for productive cough, chest pain, sputum production, dyspnea, or wheezing.

ALLERGIES:  Reports history of rhinitis.

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O.

Physical exam:

Vital Signs: BP- 112/70; RR-20; HR-84; Temp: 98.4

General:  The patient is alert, oriented, and in no acute distress. Her speech is clear and logical.

HEENT:  Pale, boggy nasal mucosa; Clear thin secretions; Enlarged nasal turbinates that obstruct airway flow. Throat: Tonsils are not enlarged; Throat is mildly erythematous.

Chest/Lungs: Lungs are clear on auscultation.

 

Cardiovascular: No neck vein distension. Regular heart rate and rhythm; S1 and S2 present.

Diagnostic results: No diagnostic tests were ordered. However, Skin tests are indicated for patients who do not improve treatment to identify specific allergens.

A.

Differential Diagnoses

Seasonal Allergic Rhinitis: This is an allergic condition attributed to plant allergens that change with seasons. Tree pollens are associated with rhinitis in spring (Emeryk et al., 2019). Symptoms include itching of the eyes, nose, or palate, rhinorrhea, sneezing, and nasal and sinus obstruction. Physical exam findings include thin watery nasal secretions edematous, blue-red nasal turbinates, nasal septum deviation or perforation, conjunctival injection, and eyelid edema (Emeryk et al., 2019). Seasonal Allergic Rhinitis is a differential diagnosis based on the patient’s history of developing symptoms of sneezing, runny nose, and itchy eyes and palate during spring. Besides, physical findings of the pale boggy nasal mucosa, clear thin secretions, enlarged nasal turbinates, and erythematous throat make it a presumptive diagnosis.

Vasomotor Rhinitis: Vasomotor rhinitis is a non-allergic type of rhinitis caused by changes in odor, temperature, or humidity. Symptoms include sneezing, rhinorrhea, nasal congestion, headache, coughing, facial pressure, and throat clearing (Agnihotri & McGrath, 2019). Physical exam findings include boggy edematous mucosa with clear mucus. Vasomotor Rhinitis is a differential diagnosis based on pertinent positive symptoms of sneezing, runny nose, clear watery mucus, and boggy edematous mucosa.

Acute Sinusitis: Clinical manifestations of Acute Sinusitis include nasal discharge, persistent cough, nasal blockage, hyposmia, irritation of the pharynx, facial pain, ear fullness, and tenderness (Jaume et al., 2020). Physical findings include purulent nasal discharge, mucosal erythema, erythema over the cheeks, nose, and eyelids, tenderness over the inflamed sinuses, purulent pharyngeal secretions, and periorbital edema. Acute Sinusitis is a differential diagnosis based on the patient’s signs and symptoms of nasal discharge, runny nose, and itchy palate.

Rhinovirus Infection: The initial symptoms of Rhinovirus infection include nasal dryness and irritation, throat irritation, and sore throat. Subsequent symptoms include sneezing, nasal discharge and congestion, ear pressure, headache, hyposmia, hoarseness, low-grade fever, and cough (Dee et al., 2021). Rhinovirus infection is a differential diagnosis based on the patient’s symptoms of

Nasal Polyposis: Nasal polyposis is an inflammatory that causes nasal obstruction, nasal congestion, hyposmia, anosmia, and persistent postnasal drainage (Pezato et al., 2019). It is a differential diagnosis based on runny nose and nasal discharge.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Agnihotri, N. T., & McGrath, K. G. (2019). Allergic and non-allergic rhinitis. Allergy and asthma proceedings, 40(6), 376–379. https://doi.org/10.2500/aap.2019.40.4251

Dee, K., Goldfarb, D. M., Haney, J., Amat, J., Herder, V., Stewart, M., Szemiel, A. M., Baguelin, M., & Murcia, P. R. (2021). Human Rhinovirus Infection Blocks Severe Acute Respiratory Syndrome Coronavirus 2 Replication Within the Respiratory Epithelium: Implications for COVID-19 Epidemiology. The Journal of infectious diseases, 224(1), 31–38. https://doi.org/10.1093/infdis/jiab147

Emeryk, A., Emeryk-Maksymiuk, J., & Janeczek, K. (2019). New guidelines for the treatment of seasonal allergic rhinitis. Postepy dermatologii i alergologii, 36(3), 255–260. https://doi.org/10.5114/ada.2018.75749

Jaume, F., Valls-Mateus, M., & Mullol, J. (2020). Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020. Current Allergy and asthma reports, 20(7), 28. https://doi.org/10.1007/s11882-020-00917-5

Pezato, R., Voegels, R. L., Pignatari, S., Gregório, L. C., Pinto Bezerra, T. F., Gregorio, L., Balsalobre, L., Tepedino, M. S., Coronel, N., Pinna, F. R., Mendes Neto, J., Oliveira, P., Macoto, E., Stefanini, R., Figueiredo, C., Haddad, F., Pilan, R., Bezerra Soter, A., Melo, N. A., Candido, D. A., … Stamm, A. C. (2019). Nasal Polyposis: More than a Chronic Inflammatory Disorder-A Disease of Mechanical Dysfunction-The São Paulo Position. International archives of otorhinolaryngology, 23(2), 241–249. https://doi.org/10.1055/s-0038-1676659

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Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Photo Credit: Getty Images/Blend Images
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
To Prepare

• By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:
• Review this week’s Learning Resources and consider the insights they provide.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

Case #2

A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.

Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

• Chapter 11, “Head and Neck”

This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.

• Chapter 12, “Eyes”

In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.

• Chapter 13, “Ears, Nose, and Throat”

The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.

Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.

Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.

Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.

Chapter 32, “Sore Throat”

A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.

Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.

Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)

Hayashi, T., Kitamura, K., Hashimoto, S., Hotomi, M., Kojima, H., Kudo, F., Maruyama, Y., Sawada, S., Taiji, H., Takahashi, G., Takahashi, H., Uno, Y., & Yano, H. (2020). Clinical practice guidelines for the diagnosis and management of acute otitis media in children—2018 update. Auris Nasus Larynx, 47(4), 493–526. https://doi.org/10.1016/j.anl.2020.05.019

Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.563627

Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031

Document: Episodic/Focused SOAP Note Exemplar (Word document)

Document: Episodic/Focused SOAP Note Template (Word document)

Document: Midterm Exam Review (Word document)

Shadow Health Support and Orientation Resources

Shadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-Video

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide

Document: DCE (Shadow Health) Documentation Template for Focused Exam: Cough (Word document)
Use this template to complete your Assignment 2 for this week.

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Optional Resource
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
• Chapter 7, “The Head and Neck”

This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck conditions.

Required Media (click to expand/reduce)

Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)
Accessible player
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

Geeky Medics. (2020, June 5). Fundoscopy (Ophthalmoscopy) – OSCE guide [Video]. YouTube. https://www.youtube.com/watch?v=SVuP5Td23AQ&feature=youtu.be

Health4TheWorld Academy Videos Channel. (2020, February 15). Paranasal sinus imaging [Video]. YouTube. https://www.youtube.com/watch?v=8TQBtdbEY-I

University of Iowa Ophthalmology. (2016, December 19). Fluorescein staining of the cornea. Retrieved from https://vimeo.com/198695974
Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from https://vimeo.com/198695974. The author(s) and publishers acknowledge the University of Iowa and EyeRounds.org for permission to reproduce this copyrighted material.

Note: Approximate length of this media program is 25 seconds.

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Rubric:

Excellent Good Fair Poor
Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

· Provide evidence from the literature to support diagnostic tests that would be appropriate for your case. 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected. 24 (24%) – 29 (29%)
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. 18 (18%) – 23 (23%)
The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.