Assessing The Head, Eyes, Ears, Nose, And Throat
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.
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.
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