Case Study

Case 1: Nose Focused 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 five 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 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.

Write a 2 page essay relating to case 1: Description of the health history you would need to collect from the patient in the case study assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five (5) different possible conditions for the patient’s differential diagnosis and justify why you selected each. Make sure you list 5.

Richard has presented with sneezing, nasal congestion, postnasal drainage, and rhinorrhea. He also reports that he has had itching in his ears, nose, eyes, and palate. His symptoms began 5 days ago.The advanced practice nurse would need to build a health history in able to accurately diagnosis Richard. A few of the questions that would need to be asked regarding Richard’s symptoms are:
Is there a family history of allergies?
Has he experienced fever, cough, headache, or malaise?
Does he have a history of experiencing these symptoms during particular times of the year?
What medications is Richard taking? It is necessary to gather over-the-counter and herbal medications that Richard may have tried, as well.Ect…..

Upper respiratory infections are one of the most prevalent conditions affecting both children and adults. Advanced practice nurses must be able to diagnose and treat these infections. He or she must be able to differentiate between whether the patient has a viral infection, bacterial infection, or allergic rhinitis (Seller & Symons, 2012).
Physical Exams and Diagnostic Tests
The advanced practice nurse must perform a physical exam on Richard to make five differential diagnosis of his symptoms. The first thing the nurse should do is to perform a general assessment. This should include observing Richard for any change in mental status (Dains, Baumann, &Scheibel, 2012). Vital signs should be taken to determine if Richard has a fever which might indicate a bacterial infection. It is essential to observe if Richard is breathing through his mouth, because this may indicate nasal obstruction from enlargement of his pharyngeal lymphoid tissue (Dains, Baumann, &Scheibel, 2012). He or she must inspect Richard’s face for periorbital edema and allergic shiners, which are black circles underneath his eyes. If Richard does have dark circles under his eyes, it is indicative of venous stasis and congestion. Periorbital edema would be a sign that Richard may have bacterial sinusitis (Dain, Baumann, &Scheibel, 2012).It is necessary for the advanced practice nurse to examine Richard’s head and neck. Examining his eyes, lymph nodes, and ears will help to determine if Richard has a sinus infection or acute rhinitis. He or she must also examine Richard’s nasal cavity for coryza, which is inflammation of his nasal mucous membranes (Dains, Baumann, &Scheibel, 2012).It is also necessary to examine Richard’s mouth and teeth. Halitosis can be indicative of sinusitis or a dental abscess. Tapping on his maxillary teeth to check for tenderness will help to determine if Richard has maxillary sinusitis (Dains, Baumann, &Scheibel, 2012).During the physical exam, the advanced practice nurse must test Richard’s sense of smell. Severe nasal congestion can cause anosmia. If Richard has a decreased sense of smell, it may indicate that he has ethmoid sinusitis (Dains, Baumann, &Scheibel, 2012).The advanced practice nurse must also palpate Richards’s frontal and maxillary sinuses. If Richard complains of tenderness or pain with palpation, it would indicate that he has a sinus infection. It is also important to palpate the frontal sinuses by exerting pressure over each eyebrow (Dains, Baumann, &Scheibel, 2012).Assessing Richard’s nasal secretions will help to develop differential diagnosis. Foul smelling purulent nasal discharge may be indicative of nasal obstruction by a foreign body. If pus is found in the ostium of Richard’s middle turbinate, he may have bacterial sinusitis (Dains, Baumann, &Scheibel, 2012).Checking Richards’s nasal passages for polyps and masses is also needed during the physical exam (Dains, Baumann, &Scheibel, 2012). Richard keeps pressing his fingers to the bridge of his nose and complains of not being able to breathe. The nurse should check for nasal septum deviation, as well (Dains, Baumann, &Scheibel, 2012).One lab test that the advanced practice nurse should order is a nasal smear. This test confirms whether there are eosinophils in the nasal secretions.  If eosinophils are present, it would confirm that Richard has allergic rhinitis (Dains, Baumann, &Scheibel, 2012).Another lab test that the advanced practice nurse can order is a blood test to check for IgE antibodies in Richard’s system. Skin tests for IgE can also help to support the diagnosis of allergic rhinitis (Tran, Vickery, &Blaiss, 2011).

The advanced practice nurse should use a nasal speculum to visual Richard’s nasal turbinates and mucosa. A head mirror will help to optimize the visualization of the nasal passages. Boggy, pale turbinates are seen in individuals suffering from allergic rhinitis while inflammation of the nasal mucosa is indicative of hay fever (Dains, Baumann, &Scheibel, 2012). Transillumation of his maxillary and frontal sinuses is needed to determine if Richard may be suffering from a sinus infection (Seidel, Ball, Dains, Flynn, Solomon, & Stewart, 2011).
In Richard’s case, I do not believe it would be necessary to obtain a sinus radiograph, computed tomography scan, or magnetic resonance imaging. Richard has only had the symptoms for 5 days, and his symptoms do not reflect that he has a sinus infection. If the advanced practice nurse was concerned that Richard had a bacterial infection, he or she could order a sinus aspiration and nasal endoscopy. If Richard’s symptoms persist, he or she should order allergy skin testing to identify what antigens are responsible for Richard’s symptoms (Dains, Baumann, &Scheibel, 2012).

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