NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5

Walden University NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

 

How to Research and Prepare for NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5                     

 

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

 

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

 

How to Write the Introduction for NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5                     

The introduction for the Walden University NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

 

How to Write the Body for NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5                     

 

After the introduction, move into the main part of the NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

 

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

 

How to Write the Conclusion for NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5                     

 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

 

How to Format the References List for NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5                     

 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5

NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5

Patient Information:

CT, 32 years old

S.

CC (chief complaint) “I feel tired and my hair is falling off”

HPI: Chantal is a 32-year-old female who visited the facility with complaints of feeling tired and her hair falling out. She reports that she has gained 30 pounds of weight in the past year. Chantal also reports that her appetite has significantly decreased. She denied accompanying symptoms such as nausea, vomiting, and pain. She reports that engaging in active physical activities worsens the fatigue that she is experiencing.

Current Medications: Chantal denies any current use of medications

Allergies: Chantal reports seasonal allergies. She denies food or drug allergies.

PMHx: Chantal’s immunization record is up-to-date. Her last tetanus vaccination was 10/10/23. She has no history of hospitalization or chronic illnesses. She also denied any history of surgeries.

Soc Hx: Chantal is married with no children. She works as a teacher. She lives with her husband in a rented apartment. She does not smoke or abuse any drugs. She loves spending her leisure time with her husband and family. She wears a seat belt while driving. Their home has smoke detectors. She engages in regular exercises at least four times weekly.

Fam Hx: Chantal’s mother was diagnosed with cervical cancer a year ago and has been on treatment. Her father is an alcoholic and has hypertension and asthma. Her paternal grandfather died of heart disease. Her paternal grandmother died of major depression. Her maternal grandmother died of diabetes mellitus type 2.

ROS:

GENERAL:  Chantal was dressed appropriately for the occasion. She was alert and oriented to herself, time, and events. She reported fatigue and weight gain. She denied fever, pain, or chills.

HEENT:  Eyes: Chantal denies blurred vision, eye drainage, pain, or double vision. Ears, Nose, Throat:  Chantal denies ear pain, decreased hearing, ringing, or ear fullness. She denies sneezing, nasal drainage, or septum deviation. She denies a sore throat, difficulty swallowing, or postnasal drainage.

SKIN:  Chantal reports her hair falling out. She denies abnormal changes in her skin color, itching, or skin rashes. CARDIOVASCULAR: Chantal denies palpitation, peripheral edema, palpitations, or chest pain and discomfort.

RESPIRATORY:  Chantal denies wheezing, cough, dyspnea, cyanosis, or sputum. GASTROINTESTINAL:  Chantal reports decreased appetite. She denies nausea, vomiting, diarrhea, heartburn, abdominal pain, or bleeding.

GENITOURINARY:  Chantal reports that her last menstrual period was 24/12/2023. She denies urgency, frequency, or dysuria.

NEUROLOGICAL:  Chantal denies loss of balance, difficulty with movement, tingling sensations, syncope, dizziness, or paralysis. Her bowel and bladder movements are normal.

MUSCULOSKELETAL: Chantal denies fractures, joint pains, muscle pain, stiffness, and back pains.

HEMATOLOGIC:  Chantal denies easy bruising and a history of excessive bleeding and bleeding disorders

LYMPHATICS:  Chantal denies any enlarged notes or a history of splenectomy. PSYCHIATRIC:  Chantal has no history of any mental health disorders

ENDOCRINOLOGIC:  Chantal reports weight gain, feeling cold, fatigue, and disturbance in her sleeping pattern. She denies polydipsia or polydipsia.

ALLERGIES:  Chantal reports a history of her hair falling out.

O.

Physical exam:

Vital signs: T 37.3, RR 20, BP 102/62, P 70, and SPO2 96%, Weight 276 lbs Height 5’5

Skin: Scarce hair distribution, dry and cold skin to touch

Diagnostic results: A complete blood count and thyroid function tests were ordered. This was to rule out infections and abnormal thyroid hormones as the cause of Chantal’s problems.

A.

Differential Diagnoses

Hypothyroidism: Hypothyroidism is Chantal’s primary diagnosis. Hypothyroidism is a thyroid disorder that develops from low thyroid hormone levels. Hypothyroidism develops due to central or secondary causes. Central hypothyroidism arises from inadequate stimulation of the thyroid gland by the central nervous system while secondary hypothyroidism develops due to other causes such as thyroid surgery. Patients suffering from hypothyroidism experience symptoms such as cold intolerance, skin changes, puffiness, decreased sweating, gastrointestinal disturbances, hair loss, voice changes, fatigue, sleep disturbances, and weight gain. They also experience galactorrhea and menstrual cycle abnormalities (Patil et al., 2023; Wilson et al., 2021). Chantal has symptoms seen in hypothyroidism, hence, her primary diagnosis.

Major depression: Major depression is the secondary diagnosis that should be considered for Chantal. Major depression is a mental health disorder characterized by a severely depressed mood on most days, throughout the day. Patients also report additional symptoms such as fatigue, feelings of worthlessness and guilt, and changes in appetite, sleep patterns, and weight. Patients are also easily distracted, and experience difficulties concentrating and making decisions, suicidal thoughts, plans, and attempts (Bode et al., 2021). Chantal has some symptoms of major depression such as weight and appetite changes and sleep disturbances. However, she does not have a depressed mood, hence; major depression is the secondary diagnosis.

Sleep apnea: Sleep apnea is the other differential diagnosis that should be considered for Chantal. Sleep apnea is a sleep disorder characterized by problems with sleeping patterns. The affected patients experience repeated episodes of interrupted sleep due to the stopping of the breathing process. Patients experience symptoms such as snoring loudly, feeling tired after a night’s sleep, gasping for air during sleep, morning headaches, and irritability (Gottlieb & Punjabi, 2020; Malhotra et al., 2021). Chantal has sleep disturbance problems, which do not qualify her for sleep apnea, hence, it being a secondary diagnosis.

Chronic fatigue syndrome: Chronic fatigue syndrome is the other differential that should be considered for Chantal. Chronic fatigue syndrome is a condition associated with symptoms such as profound tiredness despite bed rest. The symptoms worsen when patients engage in any activity that requires intensive mental or physical activity. Additional symptoms associated with the syndrome include light sensitivity, headaches; tender lymph nodes, insomnia, and difficulties with concentration (Deumer et al., 2021; Sandler & Lloyd, 2020). Despite Chantal reporting fatigue, she does not suffer from chronic fatigue syndrome because of the presence of other symptoms such as weight gain and cold intolerance.  

Addison’s disease: Addison’s disease is the other differential diagnosis that should be considered for Chantal. Addison’s disease develops from insufficient production of steroid hormones by the adrenal gland. Patients experience symptoms that include skin hyperpigmentation, low blood pressure, nausea, vomiting, diarrhea, constipation, and abdominal pain, weight loss. Patients might also experience fever, convulsions, severe gastrointestinal disturbances, and hypoglycemia during adrenal crises (Husebye et al., 2021; Saverino & Falorni, 2020). Addison’s disease is Chantal’s least likely diagnosis because of weight gain, cold intolerance, and lack of skin hyperpigmentation.

1.  

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

References

Bode, H., Ivens, B., Bschor, T., Schwarzer, G., Henssler, J., & Baethge, C. (2021). Association of Hypothyroidism and Clinical Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry, 78(12), 1375–1383. https://doi.org/10.1001/jamapsychiatry.2021.2506

Deumer, U.-S., Varesi, A., Floris, V., Savioli, G., Mantovani, E., López-Carrasco, P., Rosati, G. M., Prasad, S., & Ricevuti, G. (2021). Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): An Overview. Journal of Clinical Medicine, 10(20), Article 20. https://doi.org/10.3390/jcm10204786

Gottlieb, D. J., & Punjabi, N. M. (2020). Diagnosis and Management of Obstructive Sleep Apnea: A Review. JAMA, 323(14), 1389–1400. https://doi.org/10.1001/jama.2020.3514

Husebye, E. S., Pearce, S. H., Krone, N. P., & Kämpe, O. (2021). Adrenal insufficiency. The Lancet, 397(10274), 613–629. https://doi.org/10.1016/S0140-6736(21)00136-7

Malhotra, A., Ayappa, I., Ayas, N., Collop, N., Kirsch, D., Mcardle, N., Mehra, R., Pack, A. I., Punjabi, N., White, D. P., Gottlieb, D. J., & for SRS Task Force. (2021). Metrics of sleep apnea severity: Beyond the apnea-hypopnea index. Sleep, 44(7), zsab030. https://doi.org/10.1093/sleep/zsab030

Patil, N., Rehman, A., & Jialal, I. (2023). Hypothyroidism. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519536/

Sandler, C. X., & Lloyd, A. R. (2020). Chronic fatigue syndrome: Progress and possibilities. Medical Journal of Australia, 212(9), 428–433. https://doi.org/10.5694/mja2.50553

Saverino, S., & Falorni, A. (2020). Autoimmune Addison’s disease. Best Practice & Research Clinical Endocrinology & Metabolism, 34(1), 101379. https://doi.org/10.1016/j.beem.2020.101379

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and Treatment. American Family Physician, 103(10), 605–613.

1.  

CC:     “Fever and ear pain”

HPI:    The patient is a 3 year old girl who developed fever and ear pain that started 3 days ago.   She has no significant medical history.  The pain seems to be severe. The patient is not           pleased to be at the practioner’s office since she has been crying constantly. Her mother           states that shed developed a cold 3 days ago with sniffles. As she continues to cough she           produces a yellowish nasal discharge.

Medications: paracetamol 500mls syrup, amoxicillin 5mls syrup, ibuprofen 5mls twice daily

PMH: Has received all immunizations expected for children such as the BCG, oral polio,            and pentavalent vaccines and measles vaccine.

            Has not been previously hospitalized are undergone any surgical procedures

            Has achieved all childhood milestones expected at that age.

            Has not been transfused or transfused any blood

FH:     Mother has been diagnosed with diabetes; Father is a hypertensive patient.  No history of tuberculosis and mental illness in the family. The patient is the only child in that family.

SH:     The patient has not been exposed to second hand smoking and the parents have never             experimented with illicit drugs

Allergies: The patient has no known food or drug allergies

Immunizations: The patient is fully immunized according to EPI guidelines. Has received all             immunizations expected for children such as the BCG, oral polio,   and pentavalent           vaccines and measles vaccine.

ROS- body systems that would help with the diagnosis include the constitutional, HEENT and    respiratory.

General-Positive for fevers and no chills.

HEENT- presence of ear pain, no abnormalities on the head, positive for cough, yellowish                       discharge noted in the nose. The eyes are clear and vision is normal.

Respiratory- positive for cough, no wheezing or stridor, lung sounds are clear

Cardiovascular- Heart beat regular, no presence of murmurs and no cyanosis reported.

Gastrointestinal- No distention noted; bowel sounds normal in all areas. No splenomegaly nor   masses. No tenderness.

Pulmonary-Lungs are clear.

 

O.VS: BP 124/80; P -98; R 20; T 37.2 degrees Celsius;

The physical exam should be conducted should prioritize the constitution, HEENT and respiratory systems. These is due to the condition probably being an ear infection hence these areas should be considered to provide the more likely diagnosis. Ear infections could come from upper respiratory infections hence the respiratory system is considered. The clinical manifestations the patient also present are majorly occurring on the forenamed systems.

Constitutional- positive for fever and irritability.

HEENT- positive for ear pain, yellowish nasal discharge noted, positive for ear pain.

Respiratory- positive for cough

Diagnostics

The likely condition of the child is an ear infection hence diagnostics done should aim to prove

which one or rule out. Therefore an otoscopy should be done to examine the tympanic membrane. Tympanocentesis should also be done to determine middle ear fluid. Culture should also be done for the nasal discharge and also if there’s fluid in the middle ear. The height and weight of the child should also be obtained for medication prescription purposes.

1. Otoscopy.
2. Tympanocentesis.
3. Culture.
4. Height and weight (Hinkle & Cheever, 2014).

A.

Differential Diagnosis:

1) Acute otitis media -the clinical manifestations associated with this condition include ear pain, fever and a cough. It is known to also present with symptoms of respiratory infections hence the nasal discharge.  Patients are also known to be irritable (McCance & Huether, 2019).

2) COVID- 19- due to the recent viral infection characteristics it could be a likely diagnosis. The symptoms associated with this condition vary and have included fever, cold, irritability and presence of nasal discharge. The virus affects upper respiratory systems hence causing a wide range of symptoms (McCance & Huether, 2019).

3) Acute mastoiditis- this is due to inflammation of the air cells that could bring about clinical manifestations such as fever and ear pain. As the patient is presenting symptoms associated with ear infection this could be a likely diagnosis (McCance & Huether, 2019).

4) Herpes zoster infection is another likely diagnosis as due to the viral infection a patient presents with clinical manifestations such as irritability, fever and pain in various areas. Since the patient is a child it is a condition that is common in children hence it could be what is affecting her (McCance & Huether, 2019).

5) Acute otitis externa is another possible differential as due to inflammation of the external ear canal a patient could present with the symptoms such as ear pain irritability and a fever. Hence it is possible the patient could be suffering from this (McCance & Huether, 2019).

Primary Diagnosis/Presumptive Diagnosis: Acute Otitis Media

References

McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology:    The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical          nursing (Edition 13.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

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.

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.

Diagnostic Tests:

            In order to determine presence of IgE the immunoglobulin associated with allergies a skin prick test on the percutaneous area can be done. This test offers accuracy and sensitivity as well as being so to do. It will aid in identification of whether the patient has seasonal allergies especially to spring (Ansotegui et al., 2020).

            An additional test also done to determine susceptibility to other allergens known as skin-specific immunoglobulin (IgE) antibody test can also be done. In this reagents are used in order to determine susceptibility to specific allergens in a patient (Cox, 2020).

            A rapid influenza antigen test can also be done. This can occur through nasal swabs sampled from a patient’s nose to identify presence of influenza. It occurs through a short period of time of about half an hour and can additionally reveal if a patient is suffering from the flu though it will it reveal the type of influenza a person has (U.S. Department of Health and Human Services, 2020).

            A throat culture can also be done in order to rule out conditions such as pharyngitis (U.S. Department of Health and Human Services, 2020).

 Diagnostic results:

The nasal to test for rapid influenza antigen turned out negative

The skin prick test turned out positive to reveal a raised white bump on the skin that is has a red encirclement that is itchy.

The skin-specific immunoglobulin (IgE) antibody test turned out to be positive for dust as well as pollen.

The throat culture test was negative.

A.

Differential Diagnoses

1. Allergic Rhinitis: due to the presenting clinical manifestations and two tests conducted of the skin-prick and for the IgE screening turning out positive was indicative the patient is suffering from this condition. Additionally the reports of the condition occurring during the spring when pollen and dust is abundant in the atmosphere are in line with the occurrence of this condition (Klimek et al., 2019).
2. Streptococcus pharyngitis: This is due to a condition that infects the throat causing clinical manifestations such as congestion of the nose, itchy tonsil, a runny nose and a sore throat. This condition presents with similar clinical manifestations as the patient displayed thus making it a likely diagnosis (Sykes et al., 2020).
3. Influenza: Presence of an itchy throat and a blocked or runny nose are among the signs of influenza. These symptoms may be present in the patient. Shortness of breath, fatigue, and achy muscles are all frequent side effects (McCance & Huether, 2019).
4. Common Cold: Presence of clinical manifestations of a runny nose, itchy throat and sneezing are in line with this condition this making it a possible diagnosis (Klimek et al., 2019). 
5. Non- allergic Rhinitis: The majority of the symptoms of this illness are identical to those of its allergic counterpart. Anything that is due to a virus or bacteria to drugs could cause them. The patient also displays the previously mentioned symptoms (McCance & Huether, 2019).

Primary Diagnosis

            The patient’s condition is most likely to be allergic rhinitis. This is due to the positive tests of skin-prick and IgE test that occur in such a condition. Furthermore, the patient stated the use of Claritin to previously relieve her clinical manifestations which is known to be effective in patients suffering from this condition. Additionally, the patient stating the clinical manifestations occur in the spring is a further indication of this condition as it is during that period that there is presence of pollen and dust in the atmospheres causing such a reaction. Also, the patient’s clinical manifestations and physical exam findings are as expected in patients suffering from this condition (Klimek et al., 2019).

References

Ansotegui, I. J., Melioli, G., Canonica, G. W., Caraballo, L., Villa, E., Ebisawa, M., Passalacqua, G., Savi, E., Ebo, D., Gómez, R. M., Luengo Sánchez, O., Oppenheimer, J. J., Jensen-Jarolim, E., Fischer, D. A., Haahtela, T., Antila, M., Bousquet, J. J., Cardona, V., Chiang, W. C., Demoly, P. M., … Zuberbier, T. (2020). IgE Allergy Diagnostics and Other Relevant Tests in Allergy. The World Allergy Organization Journal, 13(2), 100080. https://doi.org/10.1016/j.waojou.2019.100080

Cox L. (2020). Overview of serological-specific IgE antibody testing in children. Current Allergy and Asthma Reports, 11(6), 447–453. https://doi.org/10.1007/s11882-011-0226-3

McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology:       The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.

Klimek, L., Sperl, A., Becker, S., Mösges, R., & Tomazic, P. V. (2019). Current therapeutical strategies for allergic rhinitis. Expert opinion on pharmacotherapy, 20(1), 83-89. https://doi.org/10.1080/14656566.2018.1543401

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M., & Beyea, J. A. (2020). Pharyngitis: Approach

            to diagnosis and treatment. Canadian Family Physician: Medecin de Famille Canadien, 66(4),251–257. https://doi.org/10.1016/j.waojou.2019.100080

U.S. Department of Health and Human Services. (2020). Influenza Diagnosis. National Institute of Allergy and Infectious Diseases. https://www.niaid.nih.gov/diseasesconditions/influenza-diagnosis#:~:text=Rapid%20influenza%20diagnostic%20tests%20can,of %20flu%20the%20patient%20has

By Day 6 of Week 5

Submit your Assignment.

Submission and Grading Information

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• Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.(extension)” as the name.
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• Click the Week 5 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria

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Week 5 Assignment 1 Rubric

Allergic rhinitis is an inflammation of the nasal membranes characterized by sneezing, nasal itching, nasal congestion, and rhinorrhea. It is triggered by reactions to airborne allergens such as dust, plant pollens, molds, animal dander, wool, and air pollutants (Bjermer et al., 2019). Clinical features of Allergic rhinitis include itching nose, eyes, ears, and palate, sneezing, rhinorrhea, postnasal drip, nasal congestion, loss of smell, headache, earache, excessive tearing, red eyes, eye swelling, fatigue, drowsiness, and malaise (Bjermer et al., 2019).

Physical exam findings in allergic rhinitis include nasal crease, thin, watery nasal secretions, deviation or perforation of the nasal septum (Crisci & Ardusso, 2020). Besides, the patient may have mouth breathing, frequent sniffling or throat clearing, and dark circles under the eyes referred to as allergic shiners. Anterior rhinoscopy typically reveals swelling of the nasal mucosa and thin, clear secretions (Bjermer et al., 2019). The mucosa of the nasal turbinates may be swollen or boggy and have a pale, bluish-gray appearance.

Allergic rhinitis is the presumptive diagnosis based on pertinent positive subjective findings of itchy nose, eyes, palate, and ears, nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Objective findings in line with Allergic rhinitis include dark circles around the eyes, excessive lacrimation, pale boggy nasal mucosa, clear thin secretions, and enlarged nasal turbinates obstructing airway flow.  Furthermore, the patient is allergic to pollen and dust mites which are documented triggers of Allergic rhinitis.

Vasomotor Rhinitis:

Vasomotor rhinitis refers to non-inflammatory rhinitis triggered by a change in temperature, odors, or humidity. It is thought to result from disturbed regulation of the parasympathetic and sympathetic systems whereby the parasympathetic system dominates, causing vasodilation and edema of the nasal vasculature (Crisci & Ardusso, 2020). The resulting symptoms include rhinorrhea, sneezing, congestion, headache, facial pressure, postnasal drip, coughing, and throat clearing. Physical exam findings in vasomotor rhinitis include boggy edematous mucosa with clear mucoid secretions (Crisci & Ardusso, 2020). In addition, mucosal injection and lymphoid hyperplasia involving the adenoids, tonsils, and lingual tonsils may be present.

Pertinent positive findings consistent with vasomotor rhinitis include nasal congestion, sneezing, rhinorrhea, postnasal drainage, boggy nasal mucosa, clear thin nasal secretions, and throat clearing.

Common Cold:

Common cold is caused by Rhinoviruses, which mainly cause upper respiratory tract infections. Clinical features of Rhinovirus infection include nasal dryness or irritation and sore throat or throat irritation, which are often the initial symptoms (Jaume, Valls-Mateus & Mullol, 2020). Nasal discharge, nasal congestion, and sneezing then occur and intensify over 2-3 days. Other signs and symptoms include headache, facial and ear pressure, loss of sense of smell and taste, cough, hoarseness, post-tussive vomiting, irritability, and in some cases, low-grade fever.

Physical exam findings in the common cold include A red nose with a profuse and dripping nasal discharge. Nasal discharge may be clear and watery or mucopurulent with a yellow or green appearance (Jaume et al., 2020). Examination of the nose reveals nasal mucous membranes with a glistening, glassy appearance, usually without erythema or edema. In addition, mildly enlarged, non-tender cervical lymph nodes are present, and chest auscultation chest may reveal rhonchi (Jaume et al., 2020). Common cold is a differential diagnosis based on pertinent positive findings of postnasal discharge, rhinorrhea, nasal congestion, sneezing, throat clearing, and clear thin secretions.

Influenza Infection

Influenza is a highly contagious airborne disease that occurs in seasonal epidemics. It manifests as an acute febrile illness with variable severity of systemic symptoms, ranging from mild fatigue to respiratory failure and death (Gaitonde, Moore & Morgan, 2019). Signs and symptoms of Influenza infection include fever, sore throat, nasal discharge, muscle pain, frontal or retro-orbital headache, weakness and severe fatigue, cough, tachycardia, and red, watery eyes (Gaitonde et al., 2019). Influenza is a differential diagnosis based on positive symptoms of nasal discharge, sneezing, and excessive lacrimation.

Acute Sinusitis

Sinusitis is characterized by inflammation of the paranasal sinuses lining. Acute Sinusitis presents with pain over the cheek, which radiates to the frontal region or teeth and increases with straining or bending down (Jaume et al., 2020). Symptoms include postnasal discharge, blocked nose, persistent coughing or pharyngeal irritation, facial pain, and a diminished sense of smell (Jaume et al., 2020). Physical exam findings include redness of the nose, cheeks, or eyelids and tenderness over the floor of the frontal sinus, purulent nasal secretions, purulent posterior pharyngeal secretions, mucosal erythema, and periorbital edema.

Pertinent positives consistent with Acute Sinusitis include nasal congestion, throat clearing, and postnasal drainage. However, the absence of facial pain or pressure and sinus tenderness symptoms makes Acute Sinusitis an unlikely primary diagnosis.

References

Bjermer, L., Westman, M., Holmström, M., & Wickman, M. C. (2019). The complex pathophysiology of allergic rhinitis: scientific rationale for the development of an alternative treatment option. Allergy, Asthma & Clinical Immunology, 15(1), 1-15. https://doi.org/10.1186/s13223-018-0314-1

Crisci, C. D., & Ardusso, L. (2020). A Precision Medicine Approach to Rhinitis Evaluation and Management. Current treatment options in allergy, 7(1), 93–109. https://doi.org/10.1007/s40521-020-00243-1

Gaitonde, D. Y., Moore, F. C., & Morgan, M. K. (2019). Influenza: Diagnosis and treatment. American family physician, 100(12), 751-758.

Greiwe, J. C., & Bernstein, J. A. (2019). Allergic and Mixed Rhinitis: Diagnosis and Natural Evolution. Journal of clinical medicine, 8(11), 2019. https://doi.org/10.3390/jcm8112019

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

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NURS_6512_Week_5_Assignment_1_Rubric

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Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: ·  Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). ·   Use clinical terminologies to explain the physical characteristics featured in the graphic.		Points Range: 30 (30%) – 35 (35%) The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.	Points Range: 24 (24%) – 29 (29%) The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.	Points Range: 18 (18%) – 23 (23%) The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.	Points Range: 0 (0%) – 17 (17%) The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.
·   Formulate a different diagnosis of three to five possible considerations for the skin graphic.    ·   Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.		Points Range: 45 (45%) – 50 (50%) The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.	Points Range: 39 (39%) – 44 (44%) The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.	Points Range: 33 (33%) – 38 (38%) The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.	Points Range: 0 (0%) – 32 (32%) The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.
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.		Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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		Points Range: 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 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.		Points Range: 5 (5%) – 5 (5%) Uses correct APA format with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors.	Points Range: 0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors.
Total Points: 100

Name: NURS_6512_Week_5_Assignment_1_Rubric

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

 

Episodic/Focused SOAP Note Template

Patient Information:

Initials: L.M                Age: 20 years old                    Sex: Female                 Race: Caucasian

S.

CC (chief complaint): “Sore throat.”

HPI: Lily is a 20-year-old Caucasian female patient who came to the clinic complaining of a sore throat that had lasted for the past three days. The patient was taking the sore throat lightly until when there was a flu outbreak at her college about two weeks ago when she got concerned that this incident might be associated with her symptoms. The patient also reported additional symptoms such as headache, pain with swallowing, and decreased appetite. She claims that some of her classmates presented with similar symptoms. She however denies chills or fever. She has not taken any medication for her present condition.

Location: Throat

Onset: 3 days ago

Character: scratchy and sore.

Associated signs and symptoms: decreased appetite, headache, running nose, and pain with swallowing

Timing: Started two weeks after a flu outbreak at her school.

Exacerbating/ relieving factors: swallowing food or drinking water worsens the pain. Gargling with warm water reduces the pain.

Severity: 6/10 pain scale

Current Medications: Multivitamin oral tablets, once daily for the past 6 months.

Allergies: Dust mite. No drug or food allergies.

PMHx: Immunization status is up to date, with the last flu vaccine received in October 2020. Her last tetanus shot was received in June 2019. The patient denies any history of medical diagnosis or surgery.

Soc Hx: The patient is a full-time college student studying economics. She enjoys spending time with his friends and reading comic books. She denies taking alcohol, cigarettes, or any other illicit drug of abuse.

Fam Hx: Patient mother has a history of diabetes and hypertension. His father was diagnosed with Gout. Her paternal grandfather died at the age of 65 years from stroke, with a history of diabetes. Her paternal grandmother is still alive with a history of HTN, and osteoarthritis. She has no information regarding her maternal grandparents.

ROS:

GENERAL: No weight loss, chills. Report fever, weakness, and fatigue. Reports decreased appetite.

HEENT: Head: Reports headache. No signs of trauma or injury. Eyes: No vision changes or double or blurry vision. The sclera has no abnormal discoloration. Ears: No hearing loss. Nose and throat: congestions, or sneezing. The patient complains of a sore and scratchy throat. The patient also reports pain with swallowing that she rates as a 6/10 severity on a pain scale for the past 3 days.

SKIN: No itchiness or rashes.

CARDIOVASCULAR: No chest pressure, pain, or any other discomfort. No edema or palpitations.

RESPIRATORY: Report shortness of breath and cough. No sputum

GASTROINTESTINAL: No nausea or vomiting, anorexia, or diarrhea. No abdominal pain.

GENITOURINARY: No burning on urination, hesitancy, no urgency, no foul odor or urine color.

NEUROLOGICAL: Reports intermittent headache for the past 3 days.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness

HEMATOLOGIC: No bruises, anemia, or bleeding.

LYMPHATICS: No history of splenectomy. Swollen lymph nodes were noted in the neck

PSYCHIATRIC: No history of anxiety or depression. Denies any history of harming self or others.

ENDOCRINOLOGIC: No reports of sweating, heat, or cold intolerance. No polydipsia or polyuria.

ALLERGIES: Dust mites

 O.

Physical exam:

General: The patient is alert and cooperative all through the examination period. She displays no signs of distress. Her vitals are T: 98.6, Pls: 85, RR: 19, BP: 105/78, and O2 99% on room air.

HEENT: Head is atraumatic and normocephalic. Pupils are round, equal, and reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. Throat with mild swelling and exudates. Tonsils are swollen. Nostrils are red and swollen.

Chest/lungs: Breathing sounds clear to auscultation

Heart: Regular heart rate and rhythm with no murmur or gallop.

Abdomen: Soft, non-distended, non-tender abdomen, with bowel sounds present in all four quadrants.

Neurological: Intermittent headache.

Diagnostic results: Complete Blood Count (CBC) 7.9: Red Blood Cells 4.7, Platelets 200, and H/H: 12.6/37.8. Throat swab culture ordered with preliminary findings reveal negative results of Group A streptococcus bacteria.

A.

1. Influenza: This is a viral infection that affects the lung characterized by upper respiratory symptoms. Patients diagnosed with this condition normally present with several signs and symptoms such as cough, fever, malaise, headache, coryza, respiratory distress, and sore throat (Chow et al., 2019). The patient in the provided case study displays most of these symptoms making it the most appropriate diagnosis. Additionally, the patient might have been infected with the virus during the flu outbreak. However, a throat culture is needed to confirm the presence of the influenza virus.
2. Acute Pharyngitis: Acute pharyngitis is a medical condition affecting the tonsils or posterior pharynx caused by microorganisms. Common symptoms displayed include sore throat, dysphagia, fever, headaches, abdominal pain, and fetid breath (Sykes et al., 2020). This condition is normally associated with acute pharyngitis. Some of the symptoms were displayed by the patient. However, no signs of abdominal pain, among others were not displayed by the patient.
3. Acute epiglottitis: This is a severe and rapidly progressing health condition characterized by sore throat, dyspnea, and hoarseness caused by Hemophilus influenza infection (Baird et al., 2018). The patient displayed most of these symptoms, however, a throat culture is needed to confirm this diagnosis.
4. Acute Sinusitis: This is a bacterial infection characterized by paranasal sinuses. Symptoms include fever, headache, nasal discharge, congestion, and cough that can occur suddenly and become worse over a few days (Ebell et al., 2019). All of these symptoms, some of these symptoms, or even none of these symptoms may occur in individuals with sinusitis, just like the patient in the provided case study.
5. Laryngitis: This is an inflammation of the larynx that can either be non-infectious or infectious. The most common symptoms associated with laryngitis include hoarseness, voice fatigue, throat pain, a sensation of lumping in the throat, and cough (Lechien et al., 2018). The patient in the provided case study displayed most of these symptoms. However, he also reported a running nose which is not experienced with this diagnosis.
6.  

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

References

Baird, S. M., Marsh, P. A., Padiglione, A., Trubiano, J., Lyons, B., Hays, A., … & Phillips, D. (2018). Review of epiglottitis in the post Haemophilus influenzae type‐b vaccine era. ANZ journal of surgery, 88(11), 1135-1140. https://doi.org/10.1111/ans.14787

Chow, E. J., Doyle, J. D., & Uyeki, T. M. (2019). Influenza virus-related critical illness: prevention, diagnosis, treatment. Critical care, 23(1), 1-11. https://doi.org/10.1186/s13054-019-2491-9

Ebell, M. H., McKay, B., Dale, A., Guilbault, R., & Ermias, Y. (2019). Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. The Annals of Family Medicine, 17(2), 164-172.       https://doi.org/10.1370/afm.2354

Lechien, J. R., Saussez, S., & Karkos, P. D. (2018). Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018. Current opinion in otolaryngology & head and neck surgery, 26(6), 392-402. doi:10.1097/MOO.0000000000000486

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257. PMCID: PMC7145142

S. CC: “Chest pain”  HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.   Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years    Allergies: PCN-rash; food-none; environmental- none   Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna ROS    General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema  Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis   O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”   General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally   Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)           A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines).   Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

A.

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

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