NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT
Patient Information:
J, Male, 13 years old
CC (chief complaint) ‘I feel pain when swallowing’
HPI: Jason is a 13-year-old patient that came to the hospital accompanied by his mother with complaints of painful swallowing. The patient reports that the problem started as a bad sore throat which worsens with swallowing. He also reports that he feels tired. His mother gave him some over the counter medication (Children’s Motrin), which made his fever better but did not help in relieving the symptoms associated with sore throat. Jayson reports that the symptoms worsen at night. The client’s symptoms started two days ago.
Current Medications: The patient reported that he currently uses children’s Motrin which his mother gave him. He does not use any other kind of medication.
Allergies: The patient denies any history of allergic reaction to food drugs or environmental allergens.
PMHx: The patient’s medical history is unremarkable. He has no history of hospitalization or any other chronic illnesses. The patient does not have any history of surgeries. His immunization history is up to date.
Soc Hx: The patient is a student. He resides with his family. He loves participating in active physical activities such as football. He wears a helmet when riding a bicycle. He denies any use of substances such as alcohol or smoking in his family.
Fam Hx: The patient’s grandfather died of depression. His grandmother is diabetic and has been on treatment for the last 20 years. His uncle was diagnosed with alcohol use disorder three months ago and is on treatment. There is no history of other chronic illnesses in the family.
ROS:
GENERAL: The patient is dressed appropriately for the occasion. He appears alert and oriented to place, time and self. The patient reports fatigue and denies weight loss, fever or chills
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion or runny nose. The patient reports sore throat which has made it difficult for him to swallow.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: denies urgency, frequency, or dysuria.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Vitals: Temperature 37.5. RR 20 breaths per minute regular, SPO2 98%
Physical exam: HEENT: There is no evidence of head injuries. Hair is equally distributed. The patient has no eye squinting. He does not use corrective lenses. There is no eye drainage or red eyes. Visual acuity is 20/20. The patient denies loss of balance or reduced hearing ability. There are normal bone and air conduction. There is no halitosis. There are no dental problems. Tonsils are edematous (2+) with stones present on the right side. He has white patches on his tongue. There is no lymphadenopathy. There is full range of motion on neck movement.
Respiratory: The patient breaths with ease. There is no nasal flaring, crackles or wheezing and cough. There is no central or peripheral cyanosis.
Cardiovascular: S1 and S2 heart sounds heard. There are no palpitations, tachycardia, chest indrawing, or edema.
Diagnostic results: Some of the recommended laboratory investigations include pharyngeal swab, sputum test and rapid antigen testing to identify the cause of the infection. Blood examinations such as complete blood count may be necessary to identify the potential cause of the infection. Methods such as complete blood count and rapid antigen testing have low sensitivity rates. CT scans may be used in cases where the care provider suspects peritonsillar abscess since it has sensitivity of up to 100%. Of all these diagnostics, the use of throat swabs and sputum culture provide the most accurate results for diagnosing patients with throat disorders such as that seen in this case study.
A.
Differential Diagnoses
Tonsillitis: Tonsillitis is the primary diagnosis for this client. Tonsillitis is the inflammation of the tonsils and contributes to about 1.3% of all the outpatient visits in America. The main causes of tonsillitis are bacterial and viral infections. Viral infections contribute to most of the cases of trump tonsillitis. Tonsillitis caused by bacterial infections are largely attributed to Group A beta hemolytic streptococcus. The affected patients present the hospital with symptoms that include fever, sore throat, tonsilla exudates and tender anterior cervical chain lymphadenopathy. There are also additional symptoms such as dysphagia and odynophagia due to tonsilla swelling. Physical examination of the tonsils may reveal swelling and erythema. There may also be tonsilla inflammation which decreases visualization of the posterior oropharynx (Al-Rawashdeh et al., 2022; Anderson & Paterek, 2022). The patient in this case study has symptoms that align with those seen in tonsillitis. For example, the patient has sore throat, dysphagia, erythema, and tonsil stones. This makes tonsillitis the client’s primary diagnosis.
Epiglottitis: Epiglottitis is the client’s secondary diagnosis that should be considered. Epiglottitis is a disorder that is characterized by the inflammation of the epiglottis. Epiglottitis develops from factors such as inflammation or trauma to the epiglottis. Patients present the hospital with symptoms such as fever, dysphagia, drooling, sore throat, muffled voice, the difficulty in breathing, and fatigue. There is also the presence of inspirational stridor and patient leaning forward to ease the breathing process (Allen et al., 2021; Dowdy & Cornelius, 2020). However, epiglottitis is the least likely diagnosis for this patient because of the lack of symptoms such as drooling, inspirational stridor, and leaning forward to ease breathing.
Pharyngitis: Pharyngitis is the other diagnosis that should be considered for this patient. It is characterized by the inflammation of the pharynx due to causes such as infections caused by bacteria or viruses. Patients may present with symptoms that are like those of tonsillitis. They include fever, sneezing, chills, headache, runny nose, fatigue, and cough (Bennett et al., 2022; Sykes et al., 2020). Despite the similarities, pharyngitis is the least likely cause of the client’s problem because there is the involvement of the tonsils. Patients with pharyngitis do not have symptoms such as tonsillitis.
Peritonsillar abscess: Peritonsillar abscess is the other secondary diagnosis to be considered for the client. Peritonsillar abscess is a complication of tonsilitis. Patients experience symptoms such as fevers, chills, dysphagia, headache, and sore throat. Peritonsillar abscess is the least possible diagnosis because of the acute nature of the patient’s symptoms.
Ludwig angina: The last differential to consider is Ludwig angina. Ludwig angina develops from infections of the submandibular space (Al-Qahtani et al., 2020). The healthcare provider should establish if the patient has a history of dental problems, which may have led to Ludwig angina. This will help rule out tonsilitis and other differential diagnoses.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Allen, M., Meraj, T. S., Oska, S., Spillinger, A., Folbe, A. J., & Cramer, J. D. (2021). Acute epiglottitis: Analysis of U.S. mortality trends from 1979 to 2017. American Journal of Otolaryngology, 42(2), 102882. https://doi.org/10.1016/j.amjoto.2020.102882
Al-Qahtani, A., Haidar, H., & Larem, A. (2020). Textbook of Clinical Otolaryngology. Springer Nature.
Al-Rawashdeh, B. M., Altawil, M., Khdair Ahmad, F., Alharazneh, A., Hamdan, L., Muamar, A. S. H., Alkhaldi, S., Tamimi, Z., Husami, R., Husami, R., & Ababneh, N. A. (2022). Vitamin D Levels in Children with Recurrent Acute Tonsillitis in Jordan: A Case-Control Study. International Journal of Environmental Research and Public Health, 19(14), Article 14. https://doi.org/10.3390/ijerph19148744
Anderson, J., & Paterek, E. (2022). Tonsillitis. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544342/
Bennett, J., Moreland, N. J., Zhang, J., Crane, J., Sika-Paotonu, D., Carapetis, J., Williamson, D. A., & Baker, M. G. (2022). Risk factors for group A streptococcal pharyngitis and skin infections: A case control study. The Lancet Regional Health – Western Pacific, 26, 100507. https://doi.org/10.1016/j.lanwpc.2022.100507
Dowdy, R. A. E., & Cornelius, B. W. (2020). Medical Management of Epiglottitis. Anesthesia Progress, 67(2), 90–97. https://doi.org/10.2344/anpr-66-04-08
Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T. W., & Beyea, J. A. (2020). Pharyngitis: Approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251–257.
