NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat

NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat

Sample Answer for NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat Included After Question

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 

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 

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

A Sample Answer For the Assignment: NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat

Title: NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat

Week 5 Assignment: HEENT Episodic/Focused SOAP Note

 Patient Information:

Initials: Kali                            Age: 44 years

Sex: Female                            Race: White

S.

CC: “My eyes are bulging and I feel fatigued.”

HPI:

Kali is a 44-year-old White woman on physical exam with primary symptoms of protruding eyes and fatigue. The symptoms began about four months ago, and the fatigue has worsened. The fatigue has no aggravating factors, but resting alleviated it to some degree. The symptoms have significantly affected her occupational functioning since she always feels tired.

Current Medications: Atorvastatin 40 mg OD for hyperlipidemia.

Allergies: No allergies.

PMHx: Vaccination is current. The last TT was four years ago, and she received a FLU shot 5 months ago. Positive history of dyslipidemia diagnosed 12 months ago. No history of surgery.

Soc Hx: Kali is a corporate secretary working in an insurance firm. She is a Certified Professional Secretary and has a Diploma in Business Administration. She is married and has two children, 20 and 17 years old. Her hobbies include baking and reading magazines. She takes 3-4 beers on weekends but denies smoking or using illicit substances. Her souse and sister are the support system.

Fam Hx: The grandmother had Diabetes, and the grandfather succumbed to Lung cancer. Her elder sister also has Diabetes. The children are well.

ROS:

Vital signs: BP- 132/84; HR-94; RR- 20; Temp- 98.4F

Wt-188 lbs; Ht-5’6; BMI- 30.3

GENERAL:  Reports fatigue and weight gain. Denies fever/chills.

HEENT:  Eyes: Positive for bulged eyes. Negative for other eye symptoms. Ears: Denies ear symptoms. Nose: Negative for sneezing, nose bleed, nasal discharge. Throat: Negative for sore throat or swallowing difficulties.

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SKIN:  Negative for skin symptoms.

CARDIOVASCULAR: Negative for edema, neck vein distension, chest pain, palpitations, or SOB.

RESPIRATORY:  Negative for respiratory symptoms.

GASTROINTESTINAL: Denies abdominal symptoms.

GENITOURINARY: Denies genitourinary symptoms.

NEUROLOGICAL: Positive for fatigue. Negative for headaches, dizziness, muscle weakness, syncope, or burning sensations.

MUSCULOSKELETAL: Denies musculoskeletal symptoms.

HEMATOLOGIC:  Denies hematologic symptoms.

LYMPHATICS: Denies lymphatic symptoms.

PSYCHIATRIC:  Negative for mood symptoms.

ENDOCRINOLOGIC: Denies endocrine symptoms.

ALLERGIES: Negative for allergic symptoms.

O.

Physical exam:

GENERAL: Female patient in her early 40s. She appears overweight, alert, and oriented. Her speech is clear and goal-directed, and she maintains eye contact throughout the session.

HEENT: Head: Atraumatic and normocephalic. Eyes: Bulging eyes bilaterally, lid lag, lid retraction, PERRLA. Ears:

NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat
NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat

Tympanic membranes are intact and shiny, with minimal pus. Nose: Moist mucous membranes, patent nostrils. Throat: Tongue is midline, and tonsillar glands are non-inflamed.

NECK: Swollen; The thyroid gland is smooth and; thyroid bruits present.

CARDIOVASCULAR: Regular heart rate and rhythm. Audible S1 and S2 with no murmurs.

RESPIRATORY: Uniform chest rise and fall; smooth respirations; Chest is clear.

Diagnostic results:

TSH levels- elevated.

A.

Differential Diagnoses

Graves disease: Grave’s disease is the most prevalent form of hyperthyroidism. The typical clinical features of Grave’s disease are increased levels of Thyroxine (T4) and enlargement of the thyroid gland. Ophthalmopathy is the hallmark of Graves disease and manifests with eye redness, swelling, upper eyelid retraction, lid lag, conjunctivitis, and bulging eyes Davies et al., 2020). Clinical symptoms include fatigue, general body weakness, sweating, warm, moist, fine skin, eye pain, photophobia, protruding eyes, double vision, heat intolerance, and weight loss despite increased appetite (Davies et al., 2020). Physical exam of the neck reveals a diffusely enlarged and smooth thyroid gland. Graves disease is a presumptive diagnosis based on positive symptoms of bulging eyes, fatigue, elevated TSH levels, thyroid bruits, and diffusely enlarged and smooth thyroid gland.

Subacute thyroiditis: Subacute thyroiditis is diagnosed based on a history of neck tenderness, respiratory tract infection, increased sedimentation rate, and inadequate or absent radioactive iodine consumption. It has a self-limited course. Local thyroid symptoms include dysphagia, pain over the thyroid area (gradual or sudden onset), and hoarseness (Stasiak & Lewiński, 2021). Constitutional clinical symptoms include fever, anorexia, malaise, fatigue, and myalgia. In stage three of the disease, TSH levels are usually elevated. Subacute thyroiditis is a differential diagnosis based on positive symptoms of swollen neck, fatigue, and elevated TSH levels.

Hashimoto Thyroiditis: Hashimoto Thyroiditis occurs due to the damage of thyroid cells by immune processes mediated by cells and antibodies. It is the most common cause of hypothyroidism. Symptoms include fatigue, energy loss, constipation, dry skin, weight gain, and bulging/protruding eyes (Ragusa et al., 2019). In addition, the TSH levels are invariably elevated. Positve clinical features of fatigue, bulging eyes, weight gain, and increased TSH levels support Hashimoto Thyroiditis as a differential diagnosis.

Goiter: Goiter presents with a distended thyroid gland (diffuse or nodular). The thyroid gland causes compresses adjacent organs causing shortness of breath, painful swallowing, stridor, nd voice hoarseness (Ragusa et al., 2019). The findings of a distended thyroid gland mae==ke Goiter a possible diagnosis.

Exophthalmos: Exophthalmos is an abnormal bulging of the eyeball. It is characterized by pupillary abnormalities. Patients also report pain, double vision, pulsation, change in effect or size with position, and disturbance in visual acuity (Topilow et al., 2020). Exophthalmos is a likely diagnosis owing to protruding eyes.

 

References

Davies, T. F., Andersen, S., Latif, R., Nagayama, Y., Barbesino, G., Brito, M., Eckstein, A. K., Stagnaro-Green, A., & Kahaly, G. J. (2020). Graves’ disease. Nature reviews. Disease primers6(1), 52. https://doi.org/10.1038/s41572-020-0184-y

Ragusa, F., Fallahi, P., Elia, G., Gonnella, D., Paparo, S. R., Giusti, C., Churilov, L. P., Ferrari, S. M., & Antonelli, A. (2019). Hashimotos’ thyroiditis: Epidemiology, pathogenesis, clinic, and therapy. Best practice & research. Clinical endocrinology & metabolism33(6), 101367. https://doi.org/10.1016/j.beem.2019.101367

Stasiak, M., & Lewiński, A. (2021). New aspects in the pathogenesis and management of subacute thyroiditis. Reviews in Endocrine and Metabolic Disorders, 1-13. https://doi.org/10.1007/s11154-021-09648-y

Topilow, N. J., Tran, A. Q., Koo, E. B., & Alabiad, C. R. (2020). Etiologies of Proptosis: A review. Internal medicine review (Washington, D.C.: Online)6(3), 10.18103/imr.v6i3.852. https://doi.org/10.18103/imr.v6i3.852