Posted: September 7th, 2022

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

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

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Assessing the Head, Eyes, Ears, Nose, and Throat
Patient Information:
R, 50-years old Caucasian male.
S.
Chief Complaint (CC):
Nasal congestion and itching for 5 days.
HPI:
Richard is a 50-year-old white male complaining of nasal congestion, sneezing and rhinorrhea, itching nose, ears, and palate, and postal drainage for 5 days. The patient reports that has taken Mucinex for the last 2 days to allow him breathe well while sleeping. He accepts that the relief from the medication is minimal. The patient denies headache or pain.
Current Medications:
Mucinex OTC 1 tablet every night.
Allergies:
NKDA, seasonal allergies.
PMHx:
No significant medical history. Denies surgery or illnesses.
PSHx:
The patient had arthroscopic meniscus repair in 2018
Sexual Reproductive History:
He is married to one wife and is sexually active.
Personal/Social History:
Takes alcohol only during celebrations. He has no history of substance and drug abuse. He eats a balanced diet every day.
Immunization History:
Immunizations are up to date. He received a flu shot last season.
Significant Family History:
He is heterosexual and sexually active. He is married to one wife, 48, and together they have one daughter, 25. The daughter has no significant medical history. The grandparents passed on 4 years ago in a car accident. They both had hypertension.
Lifestyle:
The patient is a truck driver. He attends church once a week. He lives with his family and an aunt.
ROS:
GENERAL:
AAO*4, no weight loss or gain. The patient denies headache, fever, or pain. Appears tired due to lack of sleep.
HEENT:
Eyes: Itchy and red. No changes in vision.
Ears: No hearing problem, tympanic membrane is intact.
Nose: Itchy nose and congested.
Throat: Mildly erythematous and no enlarged tonsils.
Neck: No abnormalities.
Breasts: No malignant or asymmetrical tenderness.
Respiratory: Nasal congestion, clear lung sound, shortness of breath and sputum.
Cardiovascular/Peripheral Vascular: No chest pain or discomfort or edema.
Gastrointestinal: Normal bowel movement, no diarrhea, nausea, or vomiting.
Genitourinary: The patient denies dysuria and polyuria.
Musculoskeletal: No history of bone or joint pain or injuries.
Psychiatric: No anxiety, suicidal thoughts, or depression.
Neurological: No dizziness, seizures or headache. Normal bladder control.
Skin: No skin lashes or lesions.
Hematologic: No blood disorder or bruising.
Endocrine: No abnormal sweating or fever.
Allergic/Immunologic: NKDA
LYMPHATICS: Swollen lymph nodes. No splenectomy.
ALLERGIES: NKDA
Objective Data.
Physical exam:
The general information shows that the patient is unwell.
Vital Signs: ht 5’8, wt 190, BMI 24.2.
General: A&O * 4, appears unwell with a pale and dull appearance. Dressed for the event. No bad breath and conscious of the environment.
HEENT: Eyes: Itchy and red. No changes in vision. Ears: No hearing problem, tympanic membrane is intact. Nose: Itchy nose and congested. Throat: Mildly erythematous and no enlarged tonsils.
Neck: JVD or megaly or full ROM, carotid no bruit.
Chest/Lungs: CTA AP&L, no dyspnea.
Heart/Peripheral Vascular: RRR, no murmur, peripheral pulses +2 bilaterally, no edema.
Abdomen: Normal bowel sounds plus no masses.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetrical movement, and development. The strength is 5/5.
Neurological: DTR intact, CN II – XII intact.
Skin: No rashes and bleeding, watery blisters, itchy and painful silver-colored plaques.
A.
Differential Diagnoses:
a) Allergic rhinitis:
Allergic rhinitis is a type of hay fever that occurs when the immune system overreacts. The symptoms include runny, stuffy nose, red, itchy, and watery eyes. Diagnosis involves examination of nasal passages and examination of medical history (Small et al., 2018). Allergic rhinitis occurs mostly after exposure to hay, pollen or dust. The patient is most likely suffering from allergic rhinitis due to the similarities in the symptoms.
b) Common cold:
It is a viral infection of both nose and throat. Symptoms include running nose, congestion, and sneezing (Van Driel et al., 2018). Most people recover within 2 weeks. Home remedies and over the counter drugs can relieve the symptoms.
c) Acute sinusitis
It involves inflammation of the nose and sinuses. It caused by cold and viral infection. Symptoms include headache, fever, and fatigue (DeMuri et al., 2019). Patients experience a green thick discharge from the nose.
Reflection
I have learned that patients can present with multiple symptoms, and their primary condition is not exact. It is essential to evaluate the medical history and a comprehensive assessment of the body’s various parts or organs. A comprehensive assessment shows possible conditions. An understanding of the symptoms related to head, eyes, ears, nose, and throat infections helps determine the appropriate diagnosis for the condition (Ball et al., 2019). Conditions such as allergic rhinitis can occur after patients are exposed to dust, hay, or pollen. Older adults should avoid such exposure since it can affect their respiratory system or trigger adverse effects.
Elderly patients are at risk of various infections. They should take care of their health using preventive measures and taking a balanced diet. Patient education can reduce cases of head, eyes, ears, nose, and throat infections. Patient education helps them take preventive measures that will hinder the deterioration of the conditions. The patient should avoid taking OTC drugs since some may trigger adverse effects, while others may have little or no help.

References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An Interprofessional Approach (9th ed.). St. Louis, MO: Elsevier Mosby.
DeMuri, G. P., Eickhoff, J. C., Gern, J. C., & Wald, E. R. (2019). Clinical and Virological Characteristics of Acute Sinusitis in Children. Clinical Infectious Diseases, 69(10), 1764-1770.
Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy, Asthma & Clinical Immunology, 14(2), 51.
Van Driel, M. L., Scheire, S., Deckx, L., Gevaert, P., & De Sutter, A. (2018). What treatments are effective for common cold in adults and children?. BMJ, 363, 3786.

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Tags: nose, eyes, ears, and Throat, Assessing the Head