Case Study Nose Focused Exam Discussion Paper

Patient Information:

NR, 50 year old male African American

S.

CC: “I have been having an itchy nose, eyes, palate, and ears for the past 5 days.”

HPI: NR is a 50-year-old African American man who presents to the clinic with complaints of nasal congestion, runny nose, postnasal discharge, and sneezing that have lasted for five days. He defines the pain as itchy, and it is situated around his eyes, nose, palate, and ears. The patient rates the pain as a 7 out of 10 in regards to severity. During the night, his indications are coupled with breathing problems. He has taken an expectorant the previous two nights, but has only had little alleviation.

Current Medications: Guaifenesin 600mg PO Daily for nasal congestion

Allergies: No known allergies

PMHx:  Nasal reconstruction procedure was performed as a result of a nasal injury suffered at the age of 15.

Soc Hx: Patient is an elementary school teacher, teaching at a local school. He enjoys reading books and long distance traveling. Denies alcohol, tobacco, and illicit drug use. Owns two dogs and a cat as pets.

Fam Hx: Mother died at 74 of stroke, Father currently lives with hypertension and hyperlipidemia. No family history of cancer and diabetes Case Study Nose Focused Exam Discussion Paper.

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ROS:

GENERAL: Denies weight changes, fever, chills, fatigue, and body weakness.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: Reports nasal congestion, postnasal drainage, runny nose and sneezing.

 

SKIN: Denies rash, itching and hives.

RESPIRATORY: Reports breathing difficulty when lying flat. Wet cough reported. NEUROLOGICAL: Reports recurrent headache. Denies dizziness, ataxia, paralysis, syncope, tingling or numbness in the extremities. Denies change in bladder or bowel control.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: Denies sweating, cold and heat intolerance. Denies polyuria and  polydipsia.

ALLERGIES: Denies history of eczema eczema and hives.

O.

Physical exam:

General: Patient appears fatigued.

HEENT: Excoriation of the upper lip and philtrum is noted, as is a reddening of the nose. Pale, swollen nasal mucosa with enlargement of the inferior nasal turbinate on both sides. Tonsils are swollen and slightly erythematous, as observed during the inspection.

Pulmonary: On auscultation, there were bilateral rales. On percussion, there is a dullness felt across the right lobe.

Diagnostic results: CBC, Throat swab, sputum culture and sensitivity, CT head, VQ Scan CXR.

A.

Differential Diagnoses

  • Upper Respiratory Infection: Upper respiratory tract infections are characterized as self-limited inflammation and edema of the upper airways that are accompanied by coughing but do not manifest themselves as pneumonia. Patients who have no underlying illness that might explain for their symptoms, as well as those who have no history of chronic obstructive pulmonary disease, emphysema, or chronic bronchitis, are more likely to develop this condition.. Nose, sinus, throat and large airways are all affected by upper respiratory tract infections. Acute respiratory infection is most common during the winter and fall seasons, causing indications such as congested nasal passages, low grade fever, sneezing, sore throat and throat secretions, and body pains (Buensalido, 2018).
  • Acute Laryngitis: In the initial stages of acute laryngitis, the larynx becomes irritated and congested. In accordance with the instigating organism, this may include the supraglottic, glottic, and subglottic larynx. Laryngitis is characterized by symptoms such as runny nose, postnasal discharge, scratchy throat, congestion, lethargy, and weariness. When using a flexible nasolaryngoscope, it is possible to detect swelling and redness (Shah, 2018)Case Study Nose Focused Exam Discussion Paper.
  • Allergic Rhinitis: It is related to a range of symptoms that involve the nose. When allergens, including pollen, pet dander, or dust, is inhaled, those symptoms arise (Hammer & McPhee, 2014). Itchy nose, mouth, eyes, throat, and skin are just a few of the symptoms linked with allergic rhinitis, which also includes runny nose, sneezing, and eye irritation (Hammer & McPhee, 2014). It is possible that having a pet will result in this illness. Hypersensitivity tests must be performed in order to provide a definitive diagnosis of the condition (Shelkh, 2018).
  • Sinusitis: This refers to the inflammation of the sinuses. The root of this problem might be an infection or something else entirely. Swelling of the nose may result in an obstruction of the sinuses, which may result in pain. Acute sinusitis is a bacterial illness that often begins as a cold and progresses to a more serious stage. Chronic and acute sinusitis may be caused by seasonal allergies, nasal issues, and other problems, as well as by pathogens (McCance et al., 2014). Fever, lethargy, exhaustion, nasal congestion, sneezing and post nasal discharge are some of the symptoms that may be linked with this illness.

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Primary Diagnosis: Upper Respiratory Infection

 References

Buensalido, J. A. (2018, August 09). Rhinovirus (RV) Infection (Common Cold): Practice Essentials, Background, Pathophysiology. https://emedicine.medscape.com/article/227820-overview

McCance , K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MS: Elsevier.

Shah, R. K. (2018, September 17). Acute Laryngitis Clinical Presentation: History, Physical, Causes. https://emedicine.medscape.com/article/864671-clinical#b4

Shelkh, J. (2018, September 15). Allergic Rhinitis: Practice Essentials, Background, Pathophysiology. https://emedicine.medscape.com/article/134825-overview

Case Study Nose Focused Exam Discussion Paper