Answer for NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT Patient Information:
Answer for NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT
Patient Information:
Initials: CH
Age: 28 years
Sex: Female
S.
CC (chief complaint): Runny nose and itchy eyes
HPI: Charlotte is a 28-year-old lady who presented with complaints of a runny nose and itchy eyes for 9 days. These symptoms are intermittent and occur every spring for approximately six to eight weeks. The nasal discharge is of clear mucus. There is an associated fullness and popping of ears, on-and-off sneezes throughout the day, and a tickle in the throat. There is a history of partial relief with Claritin. There is no reported cough, hotness of the body, or hearing loss.
Location: Nose and eyes.
Onset: 9 days ago.
Character: Intermittent.
Associated signs and symptoms: On and off sneezing, tickle in the throat, fullness, and popping of the ears.
Timing: Every spring for six to eight weeks.
Exacerbating/ relieving factors: Partial relief by Claritin. There is no known exacerbating factor.
Severity: Unknown.
Current Medications: The patient is currently not on any medication.
Allergies: There is no known allergy to any medication, food, or environmental components. The patient’s symptoms, however, recur every spring thus there is a possible allergy to pollen which could be the major trigger of the patient’s seasonality of symptoms.
PMH: The patient is neither hypertensive nor diabetic. There is no other reported significant chronic medical condition. The patient has never undergone any surgical procedure.
Soc Hx: The patient is an accountant. She likes traveling and photography. She is recently married with one child. There is no reported history of smoking or chronic alcohol use. She is currently lactating and is not on any contraception.
Fam Hx: The patient has a positive history of similar presentations in her grandfather. There is no family history of diabetes or hypertension.
ROS:
GENERAL: She reports no recent unintended weight loss, fever, or generalized body malaise.
SKIN: She reports no pruritus, abnormal skin discoloration, or skin rash.
CARDIOVASCULAR: She reports no left-sided chest pains, palpitations, easy fatigability, or shortness of breath even on exertion or lying flat.
RESPIRATORY: She reports no dyspnea, no chest pain, no cough, and no chest tightness.
ABDOMINAL: She reports no abdominal swelling, abdominal pain, nausea, vomiting, diarrhea, or constipation.
GENITOURINARY: She denies discomfort or burning sensation on urination, no blood in urine, and no frequency. Her menstrual cycle is regular with her last experienced menstrual period occurring two weeks ago.
NEUROLOGICAL: She denies headaches, dizziness, seizures, tingling sensation, numbness, weakness, loss of bladder and bowel control, or loss of consciousness.
MUSCULOSKELETAL: She has a history of joint swelling and tenderness with a diagnosis of gout that has since resolved with treatment.
HEMATOLOGIC: She reports no anemia, no excessive bleeding, and no easy bruising.
LYMPHATICS: She denies any lymphadenopathy, splenomegaly, or past splenectomy.
PSYCHIATRIC: She has no psychiatric history of depression, psychosis, or other mental disorder.
ENDOCRINOLOGIC: She denies excessive diaphoresis and heat or cold intolerance. She experiences polydipsia and polyuria.
ALLERGIES: She reports no history of allergic reactions.
O.
Physical exam:
VITALS: BP 102/80 mmHg, HR 72 bpm, RR 14, Temperature 98.0 F, BMI 22.0
GENERAL: The patient is in good general condition and not distressed. She is mildly dehydrated. The patient is obese.
HEENT: The head is atraumatic. Extraocular movements are intact with pupils being equally and bilaterally reactive to light. There is no scleral jaundice but there is redness of the eyes. The tonsils are not swollen but her throat is mildly erythematous. The external ear canals are free of foreign bodies or wax. The nasal mucosa is pale, boggy, and has clear thin secretions. The nasal turbinates are enlarged with resultant airway obstruction.
RESPIRATORY: The chest moves with respiration. It is resonant on percussion. There are normal vesicular breath sounds and good bilateral air entry on auscultation.
CARDIOVASCULAR: The point of maximal pulsation is in the fifth intercostal space midclavicular line. There is a normal cardiac activity in the precordium. S1 and S2 heart sounds were present with no murmurs or thrills.
ABDOMINAL: The abdomen is no abdominal distension. There is minimal tenderness in the right upper quadrant. There are no elicited masses or organomegaly. Bowel sounds are present.
MUSCULOSKELETAL: There is joint swelling, joint stiffness, or tenderness. There is no limitation in the range of motion.
NEUROLOGICAL: The patient is alert and oriented. There are no focal neurological deficits, weakness, or loss of sensation.
SKIN: The skin is warm and dry.
PSYCHIATRIC: The mood is stable with congruent affect.
Diagnostic results:
A complete blood count showed elevated eosinophilic cell count with the other differential cell count being within normal ranges. This suggests an allergic process or parasitic infestation which is unlikely based on the patient’s presentations.
Rhinoscopy showed a pale and boggy nasal mucosa covered with clear mucus. The absence of purulent nasal discharge rules out an infective process.
Skin prick test was positive for allergic reaction.
A CT scan of the head showed no evidence of basal skull fracture, chronic sinusitis, or nasal polyposis.
A.
Differential Diagnoses:
1. Allergic rhinitis: This is the most likely diagnosis. This is because the patient presented with typical nasal and non-nasal symptoms. The nasal symptoms included a runny nose and sneezing whereas non-nasal symptoms included itchy eyes, redness of the eyes, and tickling of the throat (Nur Husna et al., 2022). Allergic rhinitis can also present with eustachian tube dysfunction which manifests with features such as aural fullness, aural pressure, ear pain, and popping (Juszczak et al., 2020). The patient reported fullness of the ears and popping of the ears thus there is a possibility of eustachian tube dysfunction attributed to existing allergic rhinitis. Allergic rhinitis can be seasonal, perennial, or episodic (Emeryk et al., 2019). The patient probably has seasonal allergic rhinitis due to the recurrence of symptoms during spring which is associated with the abundance of triggering pollens. The presence of a positive family history of similar presentation may point to the genetic predisposition of the atopic condition. The effectiveness of Claritin in symptomatic relief suggests an allergic process. This is because Claritin is an antihistamine that can effectively reduce allergic reactions through the suppression of proinflammatory reactions.
2. Non-allergic rhinitis: Non-allergic rhinitis is another possible diagnosis. This is because some of the presenting complaints are similar to those of allergic rhinitis. This includes rhinorrhea, sneezing, and nasal congestion. However, non-allergic rhinitis does not display seasonality of symptoms as witnessed in the patient in this case. The presence of non-nasal symptoms such as itchy eyes makes allergic rhinitis more probable than non-allergic rhinitis. Non-allergic rhinitis of inflammatory and non-inflammatory etiologies such as post-infectious rhinitis, eosinophilic rhinitis, and medication-induced rhinitis should thus be excluded through further workups (Agnihotri et al., 2019). This will enable the formulation of a tailored appropriate management plan.
3. Eustachian tube dysfunction: This is a likely differential diagnosis. The aural fullness and popping sounds reported by the patient are characteristic of eustachian tube dysfunction (Hamrang-Yousefi et al., 2022). The presence of additional seasonal features such as itchy eyes and runny nose rules out eustachian tube dysfunction as the only diagnosis. Serious complications such as otitis media with effusion should be assessed.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
