NURS 6512 Advanced Health Assessment

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NURS 6512 Advanced Health Assessment

Chief Complaint (CC): Patient R.J. presented to the hospital with a complaint of itchy nose, palate, eyes, and ears for the past five days.

History of Present Illness (HPI): Patient R.J. is a 50 year-old Caucasian male presenting with itchiness of the palate, nose, ears, and eyes. He denies having a previous history of these symptoms, but states that the symptoms started five days ago. The location of the symptoms is the palate, the nose, the external auditory canals, and the eyes. The itchiness lasts for a few seconds and then returns intermittently. The itchiness is tickling and intense and is aggravated by heat. It is temporarily relieved by taking a cold drink but rebounds with a vengeance a while later. The symptom does not have a particular time. It is there all the time, day and night. On a scale of 1-10, patient R.J. rates the severity of the itch at 7/10 NURS 6512 Advanced Health Assessment

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Medications:

  1. Guaifenesin (Mucinex) 600 mg twice daily (OTC)
  2. Acetaminophen 500 mg PRN (OTC)

Allergies:

  1. NKDA
  2. No allergies to environmental irritants and food products

Past Medical History (PMH):

  1. Obesity with a BMI of 31.3 kg/m2. Currently on lifestyle therapy (exercise and diet).
  2. Type II diabetes mellitus since 2011.
  3. Hypertension since 2010. On nifedipine and losartan.
  4. Covid-19 in August 2020 (recovered).

Past Surgical History (PSH):

  1. ORIF left femur after a bathroom fall in 2016.
  2. Cardiac catheterization in 2014 for chest pain.

Sexual/Reproductive History:

  2. Married with three children.

Personal/Social History:

Patient R.J. denies etoh and smoking. He has a routine of doing isotonic aerobic exercise every day for at least 30 minutes as per his obesity therapy instructions. He does this by walking and jogging in his neighborhood daily. He admits to eating sufficient amounts of fresh fruits and vegetables as advised by his clinician. He avoids eating snacks in between meals despite the urge. He likes meeting friends over the weekend where he does not drink but his friends do. Some of the friends also smoke and he admits to involuntarily being a possible secondary smoker.

Immunization History:

He states that he has always had his immunizations as required. He got his booster Tdp last in the year 2012, pneumococcal vaccine in 2014, and influenza vaccine in 2017.

Significant Family History:

Both of his parents are deceased. The mother died of a heart attack (MI) at age 62 years and the father died of stroke aged 68 years. He has a younger brother who also has hypertension and is overweight. All of his three children are in good health so far.

Lifestyle:

Patient R.J. is a veteran who currently works as a security consultant. He lives with his wife and last born son in a wealthy suburb with all amenities available. He is able to meet his needs and those of his family. He however leads quite a sedentary lifestyle, save for the exercise regimen prescribed for his obesity and hypertension. He has started taking public transport some days of the week to avoid driving to work.

Review of Systems:

General: He denies having weight loss, chills, fever, fatigue, or weakness of any kind.

HEENT: Head: Denies any headache or dizziness. Eyes: Itchiness and tearing. No photophobia, diplopia, or short-sightedness. He does not wear glasses. Nose: He reports sneezing, nasal congestion, postnasal drainage, and persistent rhinorrhea. The nose is also itchy. He denies losing the sense of smell. He also denies epistaxis. Ears: There is no tinnitus, otorrhea, or hearing loss. Itchiness of the external auditory canal is however reported. He wears no hearing aids. His last ear examination was done six months ago. Throat: He denies oral ulceration, bleeding gums, or gingivitis. He uses no dental appliances and had his last dental examination done a year ago. He reports an itchy palate, a sore throat, and some dysphagia.

Neck: Reports no limitation in the range of motion but denies a history of disc compression.

Breasts: Denies the presence of lumps or rashes on the breasts.

Respiratory: He denies having a cough (productive or not), difficulty in breathing, or hemoptysis.

Cardiovascular/Peripheral Vascular: He denies any chest discomfort or chest pain. He also denies a history of intermittent claudication or overt edema.

Gastrointestinal: He has no nausea, diarrhea, or vomiting. He denies abdominal pain or any notable alterations in his bowel habits. The last bowel movement had been the previous night before the hospital visit.

Genitourinary: He denies frequency of micturition, pain on urination, oliguria, or polyuria. He is not incontinent. He is still sexually active with his wife and denies any history of STIs.

Musculoskeletal: He denies myalgia and arthralgia. His joints have the full range of motion. He denies any history of trauma or fractures.

Psychiatric: He denies any history of depression or anxiety as well as homicidal or suicidal ideation.

Neurological: He denies fainting, dizziness, or seizures. He also has no balance problems or difficulties with movement.

Skin: He denies any rash or itching.

Hematologic: He denies any history of difficulty with clotting or blood disorders.

Endocrine: He denies heat intolerance, excessive diaphoresis, or hormonal therapies.

Allergic/Immunologic: He was last tested for HIV in 2015 (negative) and denies immunodeficiency.

Physical Exam:

Vital signs: BP 125/85 regular cuff and sitting; P 78, regular; T 98.0°F; RR 16, non-labored; BMI 31.3 kg/m2 (obese).

General: A&O x 3, well-groomed with appropriate clothing for the weather and time of day. NURS 6512 Advanced Health Assessment

HEENT: PERRLA, EOMI. Pale, boggy nasal mucosa showing clear thin mucoid secretions. Enlarged turbinates obstructing air flow. Oronasopharynx has non-enlarged tonsils but the throat is erythematous. There is no overt exudate noted.

Neck: No distension of the jugular vein or carotid bruit. No enlargement of cervical glands.

Chest/Lungs: The lung fields clear with no crepitations, wheezing, rhonchi, or rales.

Heart/Peripheral Vascular: S1 and S2 audible on auscultation and regular with no murmurs. No gallop or rub detected.

Lab Tests and Results

  • CBC 8,300; RBC 5.77
  • SpO2 95% (Hammer & McPhee, 2018; Huether & McCance, 2017).

Diagnostics:

  • Lab: CRP 4 mg/L; WBC 8,300 (no leucocytosis)
  • Nasal endoscopy: enlarged turbinates and swollen nasal mucosa (Hammer & McPhee, 2018; Huether & McCance, 2017).

Differential Diagnoses

  1. Rhinitis (Hammer & McPhee, 2018; Jameson et al., 2018; Huether & McCance, 2017): This is the most likely diagnosis as it is known to cause itchiness of the nose, eyes, ears, and palate.
  2. Sinusitis (Jameson et al., 2018; Hammer & McPhee, 2018; Huether & McCance, 2017): Usually, sinusitis would occur together with rhinitis as rhinosinusitis and cause the same symptoms. It is therefore the next most likely diagnosis.
  3. Structural derangement (Jameson et al., 2018; Hammer & McPhee, 2018; Huether & McCance, 2017): This refers to anatomical derangement of the structures in the nose causing a disruption in the normal mucus production and flow.
  4. Foreign body (Hammer & McPhee, 2018; Jameson et al., 2018; Huether & McCance, 2017): This is an unlikely but possible diagnosis.
  5. Ciliary dyskinesia (Jameson et al., 2018; Hammer & McPhee, 2018; Huether & McCance, 2017): This is a condition of abnormal cilia and is also associated with infections. It is the least likely diagnosis as it is usually related to infertility. Patient R.J. is fertile.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. Elsevier, Inc.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2018). Harrison’s principles of internal medicine, 20th ed. McGraw-Hill Education.

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. NURS 6512 Advanced Health Assessment

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.

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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.

CASE STUDY 1: Focused Nose Exam

Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: NURS 6512 Advanced Health Assessment

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

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

RESPIRATORY:  No shortness of breath, cough or sputum.

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

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NURS 6512 Advanced Health Assessment

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

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

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

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

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.

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

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.  NURS 6512 Advanced Health Assessment