NURS 6512 Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Episodic/Focused SOAP Note Template

Patient Information:

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Initials: Richard

Age: 50

Sex: Male

Race: African American

CC (chief complaint): “Itchy nose, eyes, palate, and ears.”

HPI: Richard is a 50-year-old AA male with a chief complaint of itchy nose, eyes, palate, and ears that began five days ago. The itchiness is accompanied by nasal congestion, sneezing, rhinorrhea, and postnasal drainage. The patient mentions taking Mucinex OTC for the past two nights to ease nasal congestion while sleeping. The Mucinex has only brought minimal improvement in alleviating the nasal discharge.

Current Medications: OTC Mucinex.

Allergies: Seasonal allergies at this time of the year. No food or drug allergies.

PMHx: Immunization is up to date. Last TT- 6 years ago; Last Flu shot-5 months ago.

Soc Hx: Richard is a civil engineer working in a construction firm. He lives with his wife of 22 years, and they have two children aged 19 and 17. He smokes 1PPD and takes beer 2-3 beers for 4-5 days a week. He has no history of illicit drug use. His hobbies are watching basketball and reading magazines. He has a private medical insurance. He reports taking at least three meals daily and sleeping 5-6 hours daily.

Fam Hx: The maternal grandmother had HTN and Alzheimer’s. The paternal grandfather had prostate cancer, diabetes, and kidney failure. The father died from a stroke at 76 years. The mother is alive but has arthritis. His siblings and children are alive and well.

ROS:

GENERAL: Denies weight changes, fever, chills, or increased fatigue.

HEENT: Eyes: Reports itchy and teary eyes. Denies visual changes or yellowing sclera. Ears: Positive for itchy ears. Denies tinnitus, hearing loss, or ear discharge. Nose: Positive for itchy nose, nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Throat: Reports itchy palate.

SKIN: Denies itching, bruises, or lesions.

CARDIOVASCULAR: Denies edema, palpitations, chest pain, or dyspnea on exertion.

RESPIRATORY: Denies breathing difficulties, cough, wheezing, or sputum.

ALLERGIES: Reports seasonal rhinitis.

Physical exam:

Vital signs: BP- 122/80; RR-16; HR-76; Temp-98.4

General assessment: The patient is alert, oriented, and in no distress. He is neat and dressed appropriately. He has an upright posture and a normal gait.

HEENT: The head is symmetrical and atraumatic. Eyes: Red and teary; Cornea injection; PERRLA; Pink conjunctiva. Ears: Normal cerumen; TMs are shiny and intact. Nose: Pale, boggy nasal mucosa; Clear, thin secretions; Enlarged nasal turbinates that obstruct airway flow; Well-aligned nasal septum. Throat: The throat is mildly erythematous; tonsils are not enlarged.

CARDIOVASCULAR: Normal heart rate and rhythm. S1 and S2 are audible. No murmurs.

RESPIRATORY: Smooth respirations with uniform chest expansion. Lungs are clear bilaterally.

Diagnostic results:

Appropriate diagnostic tests for this patient include:

Percutaneous skin test- To identify the patient’s specific allergens that cause seasonal rhinitis (Lesslar & Smith, 2021).

Differential Diagnoses

Allergic rhinitis: Allergic rhinitis presents as nasal congestion, sneezing, and rhinorrhea, and the congestion worsens with time. Seasonal and perennial allergic rhinitis manifests with systemic symptoms, including malaise, weakness, and fatigue (Nur Husna et al., 2022). Furthermore, itch is a hallmark of allergic rhinitis and occurs in the hard palate, upper and lower conjunctiva, cornea, ears, and floor of the oral cavity (Lesslar & Smith, 2021). The patient reports having seasonal rhinitis, which makes Allergic rhinitis the likely primary diagnosis. In addition, he has positive symptoms like nasal congestion with clear, thin nasal secretions, sneezing, rhinorrhea, postnasal drainage, and an itchy nose, eyes, palate, and ears.

Viral Pharyngitis: The chief symptom of viral Pharyngitis is Sore throat. This is accompanied by nasal symptoms, like sneezing, congestion, watery nasal discharge, and postnasal discharge. Throat symptoms are usually in the form of scratchiness, irritation, or soreness (Sykes et al., 2020). Nasal discharge can be thick and yellow, and patients may have nonproductive cough, Oropharyngeal erythema, and Tonsillar hypertrophy. A low-grade fever is also common (Sykes et al., 2020). The patient has positive symptoms, including nasal congestion, sneezing, rhinorrhea, and postnasal drainage. He also has throat symptoms like throat irritation and mildly erythematous throat.

Vasomotor Rhinitis: Vasomotor rhinitis is unrelated to a specific allergen or cause. It occurs in patients with perennial symptoms related to temperature changes, humidity, alcohol ingestion, and odors. Symptoms mostly include nasal congestion, hypersecretion, pruritus, and sneezing (Agnihotri & McGrath, 2019). This differential diagnosis is based on nasal congestion, sneezing, rhinorrhea with thin nasal secretions, and itchiness in the nose, eyes, palate, and ears.

Viral Upper Respiratory Infection (URI): Viral URI primarily presents with rhinorrhea, nasal congestion, sneezing, sore throat, cough, general malaise, and low-grade fever (Barrett, 2018). In addition, nasal mucosal erythema and edema are common, and patients have profuse nasal discharge (van Doorn & Yu, 2020). The patient has clinical symptoms aligned with Viral URI, including rhinorrhea, nasal congestion, sneezing, and itchy throat, which is mildly erythematous.

Acute Rhinosinusitis: The signs and symptoms of Rhinosinusitis include purulent rhinorrhea, nasal congestion and obstruction, facial pain, pressure, or fullness worsened by bending forwards, frontal headache, and maxillary toothache (Jaume et al., 2020). The symptoms often occur following an upper respiratory tract infection. The patient has nasal congestion, obstruction, and rhinorrhea, which occur in Rhinosinusitis.

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 nonallergic rhinitis. Allergy and asthma proceedings, 40(6), 376–379. https://doi.org/10.2500/aap.2019.40.4251

Barrett, B. (2018). Viral Upper Respiratory Infection. Integrative Medicine, 170–179.e7. https://doi.org/10.1016/B978-0-323-35868-2.00018-9

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

Lesslar, O. J. L., & Smith, P. K. (2021). Itch Beyond the Skin-Mucosal Itch. Frontiers in allergy, 2, 700368. https://doi.org/10.3389/falgy.2021.700368

Nur Husna, S. M., Tan, H. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic Rhinitis: A Clinical and Pathophysiological Overview. Frontiers in medicine, 9, 874114. https://doi.org/10.3389/fmed.2022.874114

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T. W., & Beyea, J. A. (2020). Pharyngitis: Approach to diagnosis and treatment. Canadian family physician Medecin de famille canadien, 66(4), 251–257.

van Doorn, H. R., & Yu, H. (2020). Viral Respiratory Infections. Hunter’s Tropical Medicine and Emerging Infectious Diseases, 284–288. https://doi.org/10.1016/B978-0-323-55512-8.00033-8

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

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.

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.

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.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th 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”

Download 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”
Download 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”
Download 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”
Download 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”
Download 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”

- Download 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.

Document: Episodic/Focused SOAP Note Exemplar

Download Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template
Download Episodic/Focused SOAP Note Template (Word document)
Document: Midterm Exam Review

Download Midterm Exam Review (Word document)

Shadow Health Support and Orientation Resources

Shadow Health. (2021). Welcome to your introduction to Shadow Health

Links to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
Shadow Health. (n.d.). Shadow Health help desk
Links to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us
Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students.
Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
Document: DCE (Shadow Health) Documentation Template

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

Required Media

Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)

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)

Links to an external site. – OSCE guide [Video]. YouTube. https://www.youtube.com/watch?v=SVuP5Td23AQ&feature=youtu.be
Health4TheWorld Academy Videos Channel. (2020, February 15).Paranasal sinus imaging
Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=8TQBtdbEY-I
University of Iowa Ophthalmology. (2016, December 19).Fluorescein staining of the cornea

Links to an external site.. Retrieved from https://vimeo.com/198695974
Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from â€‹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.

Optional Resources

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

Links to an external site.. 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
Links to an external site.. 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
Links to an external site.. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031
- Links to an external site.
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.

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.

By Day 6 of Week 5

Submit your Assignment.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

To submit your completed assignment, save your Assignment as WK5Assgn1+last name+first initial.
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select Submit Assignment for review.

Rubric

NURS_6512_Week_5_Assignment_1_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome 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.

50 to >44.0 ptsExcellent

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.

44 to >38.0 ptsGood

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.

38 to >32.0 ptsFair

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.

32 to >0 ptsPoor

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.

50 pts

This criterion is linked to a Learning Outcome · List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

35 to >29.0 ptsExcellent

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.

29 to >23.0 ptsGood

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.

23 to >17.0 ptsFair

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.

17 to >0 ptsPoor

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.

35 pts

This criterion is linked to a Learning Outcome 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 to >4.0 ptsExcellent

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 to >3.0 ptsGood

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 to >2.0 ptsFair

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.

2 to >0 ptsPoor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts

This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 ptsFair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 ptsPoor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning Outcome 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 to >4.0 ptsExcellent

Uses correct APA format with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) APA format errors.

3 to >2.0 ptsFair

Contains several (3 or 4) APA format errors.

2 to >0 ptsPoor

Contains many (≥ 5) APA format errors.

5 pts

Total Points: 100