Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

 

The case study to concentrate on:
use SOAP note format for the paper there is an attachment of SOAP note example

Case 1: Nose Focused 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 two 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.
The paper should be a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical
exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s
differential diagnosis and justify why you selected each.
*Book: Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier
Mosby. Chapter 10, “Head and Neck” (pp. 184-203)
*Dains, J. E., Baumann, L. C., Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 15, “Earache” (pp. 174–183)
*Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for head, face, and neck. In
Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

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