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

SUBJECTIVE DATA

Chief Complaint (CC): For the past 5 days I have had nasal congestion, sneezing, and my nose and eyes have been itchy.

History of Present Illness (HPI): Richard is a 50 year old white male in the clinic today with a complaint of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. He denies fever, nausea or vomiting. 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. This past week he has been helping a friend in his hay field. Symptoms began a day or two after.

Medications:

Mucinex OTC QHS PRN

Lisinopril 20mg PO QD

Allergies:

NKDA

Past Medical History (PMH):

HTN

Past Surgical History (PSH):

Plate placed in left ankle and at 25 from MVA

Sexual/Reproductive History:

Heterosexual

Married, 2 children who are living outside the home

Personal/Social History:

Denies alcohol use, smoking, or drug abuse

Immunization History:

Unknown last Tdap, flu 2014

Significant Family History:

One brother, alive and no health history. Mother died from lung CA 2 years ago (age 73). Father is 76, alive and has a hx of HTN, DM and Alzheimer’s. Children are both healthy.

Review of Systems:

HEENT: nasal congestion, sneezing, runny/itchy nose, itchy eyes and ears x 5 days

Respiratory: Denies SOB, coughing, sputum production and lungs clear

Gastrointestinal: No change in bowel habits. No nausea, vomiting, diarrhea, or constipation.

GU: No dysuria, incontinence or other abnormalities

Skin: No rashes, itching, bruising. No open wounds or lacerations.

OBJECTIVE DATA

Physical Exam

Vital signs:

BP 136/74 R arm, sitting

P 79, regular

T 98.3 oral

RR 18, non-labored

Wt 223; Ht 6’1”

General: A&OX3, clean, appears ill

Neuro: AAO x4, appropriate behavior

HEENT: Denies vision or hearing alterations. Wears prescription readers. Reports allergy season being a problem this year, which is new. Lack of small/taste. Tonsils normal. Denies oral abnormalities, last saw dentist one month ago.

Neck: no abnormalities noted.

Heart: normal rate, regular, no murmur noted

Lungs: Lung sounds clear bilaterally.

Abdomen: Bowel sounds X 4 quadrants, no abnormalities noted

Genital/Rectal: not assessed

Skin: dry, warm

Musculoskeletal: no abnormalities noted

ASSESSMENT

Lab Tests/Exams and Results:

CBC-WNL

Flu Swab-Neg

Rapid Strep-Neg

Differential Diagnosis (DDx):

1. Rhinovirus- More than any other illness, rhinoviruses are associated with the common cold. Rhinoviruses may also cause some sore throats, ear infections, sinus infections (Kennedy, Heymann, & Platts-Mills, 2012).Symptoms include sore throat, runny nose, nasal congestion, sneezing and cough; sometimes accompanied by muscle aches, fatigue, malaise, headache, muscle weakness, or loss of appetite (Kennedy, Heymann, & Platts-Mills, 2012).

2. Acute sinusitis- Inflammation of one or all of the paranasal sinuses is often referred to as sinusitis –can be it infectious or non-infectious in etiology (Hawthorne & Ahmad, 2010). The vast majority of infectious causes are acute, self-limited viral infections (Hawthorne & Ahmad, 2010). Symptoms include: nasal obstruction/congestion; anterior discharge/postnasal drip; facial pain/pressure and/or reduction/loss of smell (Hawthorne & Ahmad, 2010).

3. Allergic rhinitis- Allergic rhinitis, also called hay fever, is the group of uncomfortable symptoms that occur when your body is exposed to a specific allergen (de Corso et al., 2014). An allergen is a typically harmless substance, such as grass or dust, which causes an allergic reaction (de Corso et al., 2014). Pollen is the most common allergen for most people (de Corso et al., 2014). Since Richard has been working in the hay field the week prior, this concludes the diagnosis. Uncomfortable symptoms of allergic rhinitis include runny nose, sneezing, and itchy eyes (de Corso et al., 2014).

4. Sinus obstruction- The sinuses are small, hollow chambers inside the nose and head that reduce the weight of the facial bones, give the bones shape and support, assist in mucus drainage from the nose, and help the voice resonate (Kennedy & Borish, 2013).Healthy sinuses are filled with air. When their mucous membranes swell from allergies, the common cold, infection or other causes, the narrow sinus openings become blocked, the pressure inside them drops, and they can fill with fluid, which easily leads to bacterial infection (Kennedy & Borish, 2013).

5. Chronic Sinusitis- Chronic sinusitis is a common condition in which the cavities around nasal passages become inflamed and swollen — for at least eight weeks, despite treatment attempts (Kennedy & Borish, 2013). This condition interferes with drainage and causes mucus to build up. It can make it difficult to breathe through your nose. The area around your eyes and face may feel swollen, and you may have throbbing facial pain or a headache (Kennedy & Borish, 2013). Symptoms of chronic sinusitis are less obvious and may include nasal blockage or congestion, post-nasal drip, reduced sense of smell, and malaise (Kennedy & Borish, 2013).

References

de Corso, E., Battista, M., Pandolfini, M., Liberati, L., Baroni, S., Romanello, M., & ... Paludetti, G. (2014). Role of inflammation in non-allergic rhinitis. Rhinology, 52(2), 142-149. doi:10.4193/Rhin

Hauk, L. (2014). AAP releases guideline on diagnosis and management of acute bacterial sinusitis in children one to 18 years of age. American Family Physician, 89(8), 676-681. Retrieved from: http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=8&sid=642c28f0-7af4-4bb2-b3b0-bafbb5861d8a%40sessionmgr110&hid=106

Hawthorne, M. R., & Ahmad, N. (2010). Acute sinusitis: pitfalls in diagnosis and management. Clinical Risk, 16(6), 209-212. doi:10.1258/cr.2010.010052

Kennedy, J. L., & Borish, L. (2013). Chronic sinusitis pathophysiology: the role of allergy. American Journal Of Rhinology & Allergy, 27(5), 367-371. doi:10.2500/ajra.2013.27.3906

Kennedy, J. L., Heymann, P. W., & Platts-Mills, T. E. (2012). The role of allergy in severe asthma. Clinical And Experimental Allergy: Journal Of The British Society For Allergy And Clinical Immunology, 42(5), 659-669. doi:10.1111/j.1365-2222.2011.03944.x