NURS 6512 Week 5 Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat Paper

 NURS 6512 Week 5 Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat Paper

 NURS 6512 Week 5 Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat Paper

Episodic/Focused SOAP Note

Patient Information:

D.R., a 8 years old boy of  Hispanic origin


CC (chief complaint) “I have had a consistent cough for the last 5 days, and due to not sleeping well, I feel fatigued”.

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HPI:  A young boy of Hispanic origin comes to the clinic and discloses that he has had a persistent cough that began five days ago. He states that the problem worsens at night, making him have an insufficient sleep. The sleep insufficiency makes him experience fatigue. The cough is watery even though he has clear sputum. The patient coughs frequently; however, the cough does not become worse by engaging in any physical activity. He also indicates to be having pain in the right ear (2/10) and throat, which is slightly stronger at 3/10. The patient’s parent gave him a non-prescribed cough syrup which offered him temporary relief.

Current Medications: The patient currently consumes vitamins on a daily basis and unidentified cough syrup.

Allergies: The patient has no allergies to medications or foods.

PMHx: The patient has had consistent ear infections and was recently infected by pneumonia which was treated. However, he has no past surgeries.

Fam Hx: The patient’s father is a cigar smoker and also had asthma during his earlier years.


General: Denies any fevers, chills, or night sweats. Reports no change in appetite or usual activities. Indicates to be experiencing fatigue.

Skin: No skin rashes or any changes.

HEENT: No headaches, denies blurred vision or vision changes. Experiences pain in the throat and right ear. However, there were no changes in hearing ability.

Respiratory: Denies any breath, shortness, or wheezing. However, the patient indicates that he has had a cough for the last five days.

Cardiovascular: Denies any chest pain, tightness, or palpitations

Gastrointestinal: No vomiting, diarrhea, constipation, or abdominal pain. The appetite is normal.



Physical exam:

General: The patient is well dressed, maintains desirable eye contact, and is stable but looks fatigued.

Skin: No observed wounds, lesions, or skin rashes.

Head: Normocephalic and atraumatic

Eyes: The eyes look dull, but no discharge was noted. The patient’s conjunctiva is moist and pink with a white sclera.

Ears:  There is inflammation of the right tympanic, and it appears red. No fluids or perforations were observed. The left year appears normal, with the tympanic membrane pearly gray.

Nose: The mucus membrane is moist and produces a clear discharge.

Throat: The back of the throat has some redness observed.

Lymph nodes: palpation revealed some tenderness, with the right cervical lymph nodes being bigger.

Respiratory: has a high respiratory rate. Has a productive cough with clear sputum. Has clear breath sounds with no noted adventitious breath sounds noted.

Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)


Differential Diagnoses

From the observation and the physical assessment accomplished, the following differential diagnoses apply.

  1. Common cold: The patient reports a sore throat and stuffy nose, which are some of the symptoms of the common cold. This observation was also supported by a physical examination which showed that the patient had swollen lymph nodes.
  2. Strep throat- The sore throat shown by the patient points to a possible strep throat. The other symptoms such as nausea, vomiting, headache, and fever were, however, missing.
  • Rhinitis: This is another possible condition as the patient presented with nose drainage, sore throat, and stuffy nose. Besides, the patient has a history of recurring infections of the ear.
  1. Asthma and allergies: The patient has no history of allergies. However, this condition is possible. The consistent cough could point to the condition. However, the patient does not show any wheezing, chest pain or tightness, or shortness of breath.

Primary Diagnosis/Presumptive Diagnosis: Common cold

For further care and management of the patient, the patient needs to be referred for further diagnostic procedures, which can help in ruling out or confirming various observations. One of the further tests is an allergy test which will help in confirming or ruling out any allergic reactions. A step culture is also indicated. Through a rapid strep test, the suspected strep throat can be confirmed or ruled out (Bickely et al., 2020). The test is for the identification of bacterial infection. From the outcomes of the tests conducted, the patient can use various prescribed medications. A prescribed cough should be administered to the patient for a period of ten days while offering the necessary education for him and the mother on the medication use and potential side effects.

Allergens are known to trigger coughs, and therefore, as part of the educational effort, the patient and the mother should be advised to eliminate or avoid possible allergens (Sexton et al., 2019). The child’s beddings should also be clean and free from dust, hence should be cleaned regularly. From the history, it was noted that the patient’s father is a cigar smoker. Smoke can worsen the situation or cause a new attack. Therefore, he has to be advised to smoke away from the child. In terms of follow-ups, the patient needs to visit the facility in a fortnight for review and assessments. However, they should seek medical attention immediately in case other symptoms such as fainting, chest pain, dizziness, shortness of breath, and high fever appear.


Brooker, C. (2021). Cough and cold: The perils of the season. AJP: The Australian Journal of Pharmacy102(1206). Doi: 10.3316/informit.789777137910856

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ pocket guide to physical examination and history taking. Lippincott Williams & Wilkins.


Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Assignment 2: Digital Clinical Experience: Focused Exam: Cough. DUE 4/3/22

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