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  Jon Teegardin
  

A thorough assessment of a patients head, eyes, ears, neck, and throat can reveal a wealth of objective information that is useful in developing nursing diagnoses. Careful attention to the patient’s subjective information and objective information obtained during the assessment will contribute to positive outcomes. This paper will address two presentations, a pediatric patient with ear pain, and an adult with thyroid related problems.

Patient 1

The first patient is a 2 year old female that presents with her mother. The mother reports the patient is fussy, unwilling to eat, has nasal drainage, and is tugging at her right ear.

After introducing myself, the mother identifies the patient using two identifiers, name and birthdate. The information provided by the mother is verified against the chart and an identifying wristband is applied to the patient. A wristband is applied to the mother as well, to aid staff in identifying the mother as well as the patient. The mother reports that over the past three days, the patient has become increasingly irritable, is not eating well, and is tugging at her right ear. The mother further states that the patient was sent home from daycare because of a low grade fever and nasal congestion. The mother states she has tried giving the patient Benadryl and children’s Tylenol, but it hasn’t helped.

I continue with my interview by asking about the child’s health history and medication allergies. The mother states the child has no allergies and takes no prescription medications. She reports that the child has been healthy, and was a full term, normal birth with no complications.

After obtaining subjective data from the mother, the physical assessment begins. The patient is allowed to sit on the mothers lap. To avoid undue stress to the patient, a focused assessment is performed. The patients vital signs are as follows: heart rate 128 beats per minute, respirations 22 per minute, even and unlabored, 100% oxygen saturation, oral temperature of 99.6, and a weight of 28 pounds or 12.7 kilograms. The patient is observed tugging at her right ear during the assessment. The right ear is examined using an otoscope. The otoscope exam is performed on a child by gently pulling the auricle of the ear downward and backward (Jarvis, 2012). This process will move the acoustic meatus in line with the canal. The otoscope is held like a pen/pencil and the little finger is used as a fulcrum. This prevents injury should the patient turn suddenly. The tympanic membrane erythematous, lacks luster, and is bulging. The cone of light is distorted. The manubrium, and short process of the malleus are difficult to visualize. The left ear is examined and reveals a glistening, translucent non-erythematous tympanic membrane with light reflex extending anteriorly/inferiorly from the umbo. The manubrium and short process of the malleus are well identified. No drainage is noted from either ear. Continuing the assessment, the eyes are clear with no redness or conjunctiva. The pupils are equal and reactive to light. The nares are bilaterally obstructed with clear sinus drainage. The patient has good dentition. Her lips, tongue, oral mucosa, and uvula are unremarkable. The patient’s lungs are auscultated and her respirations are even and unlabored. An apical heart rate of 129 beats per minute is auscultated, with a normal S1 and S2. At this time the patient becomes agitated and the physical assessment is completed.

Summary of findings

The patient has acute otitis media in her right ear, along with sinusitis. Children, especially those ages one to six years are at particular risk for acute otitis media because they have very narrow Eustachian tubes (Jarvis, 2012). Children in daycare are highly prone to getting upper respiratory tract infections, so they tend to get more ear infections as well (Baylor College of Medicine, 2014).

SOAP note

S: The patient’s mother reports irritability, decreased appetite, and tugging at the right ear.

O: The patient is a nontoxic appearing white female child of approximately 2 years of age. The patient is slightly febrile (99.6), sinus drainage is noted from both nares. The right ear shows a tympanic membrane that is erythematous and bulging. The left ear appears healthy. The nares are occluded bilaterally with clear sinus drainage. The mouth and dentition are unremarkable. PERRLA at 3mm noted. Regular apical rate with S1 and S2, no S3 or S4 noted. Respirations are even and unlabored. Lungs are clear to auscultation bilaterally.

A: The patient appears to be suffering from acute otitis media and sinusitis. Because of the child’s age, an RSV (respiratory syncytial virus) specimen is obtained from the nares and sent to the lab. A normal result would be negative. Positive would indicate a viral infection. The lab results are negative for RSV.

P: The patient will be treated with amoxicillin suspension at twenty five milligrams per kilogram divided into two doses per day (Medscape, 2014). This amounts to one hundred fifty eight milligrams every twelve hours, for five days. Children’s ibuprofen is also prescribed at a rate of ten milligrams per kilogram every 4-6 hours as needed for fever (Medscape, 2014). Ibuprofen is prescribed rather than Tylenol to minimize stomach upset for the patient. The mother will be instructed to keep the child hydrated with fluids and to return to ER if the child’s fever exceeds 102.5, the child begins vomiting, or if a reaction to the amoxicillin is noted, such as rash, itching, or any difficulty breathing.

Patient 2

Patient two is a 51 year old female that reports fatigue, difficulty swallowing, increased sensitivity to cold, weight gain of twelve pounds in two months, and weakness over the past four months.

The patient is escorted to an exam room, I introduce myself and properly identify and apply a wristband to the patient. The patient is asked about allergies and medication. She reports that she has no allergies, and currently takes a blood pressure medicine. She also reports she has been to a dermatologist because her skin has been dry and she was instructed to use over the counter moisturizers that aren’t working very well.

After interviewing the patient, the physical assessment begins. Vital signs are obtained: Blood pressure 118/82, heart rate 51 beats per minute, 16 respirations per minute, temperature 98.5 degrees, weight of 184 pounds.

The patient has short hair that is clean and well groomed. She denies any hearing problems, visual problems, congestion or cough. No drainage is noted from her ears, the eyes are clear with no redness or conjunctiva. Pupils are equal and reactive to light. Nares are clear bilaterally without swelling. The patient has good dentition. The lips, tongue, oral mucosa, and uvula are unremarkable. Facial symmetry is good with no drooping. The patient’s neck is supple with full range of motion and the trachea is midline. The thyroid is examined closely based upon the patient’s subjective information. The patient is seated and asked to slightly extend her neck. A portable light is used to provide cross lighting for the initial visual examination. The patient is asked to swallow and no appreciable difference is noted with the light applied from the right or left side. After completing anterior inspection of the thyroid, the neck is observed in profile. A smooth, straight contour is visualized from the cricoid cartilage to the suprasternal notch. An anterior palpation is done next. First the thyroid isthmus is located by palpating between the cricoid cartilage and the suprasternal notch. One hand is used to move the sternocleidomastoid muscle and the other hand is used to palpate the thyroid (Jarvis, 2012). The patient is asked to swallow and the upward movement of the thyroid gland is felt. To palpate the other side, the procedure is reversed. The left lobe of the patient’s thyroid feels fuller and moves slightly less than the right side. The patient reports pain on the left side during palpation.

Alternatively, a posterior approach to examination of the thyroid can be performed (Jarvis, 2012). Standing behind the patient, locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch. Once this landmark has been located, the hands are moved laterally to feel under the sternocleidomastoids for the thyroid. The patient is asked to swallow, and upward movement of the thyroid gland is felt.

Respirations are clear and even bilaterally. The heart is auscultated and is strong and even at 52 beats per minute. Normal S1 and S2 are present. The patient denies any pain or mass in the breasts and reports that she self-examines monthly and her last mammogram was within the last twelve months. Hand grips are strong and equal, radial pulses are strong and equal bilaterally. The abdomen is soft and non-tender to palpation. Bowel sounds are present in all four quadrants. Foot strength equal bilaterally, with strong bilateral pedal pulses. The patient’s mood and affect are appropriate for her age and the current situation. The skin is somewhat dry and flaky, despite the patient’s report of applying moisturizing lotion. Her speech is clear.

Summary of findings

The patient has a palpable abnormality in her thyroid gland. Additionally, she has non-symptomatic bradycardia with an apical heart rate of 52 beats per minute. Her skin is dry.

SOAP note

S: The patient reports reports fatigue, difficulty swallowing, increased sensitivity to cold, weight gain of twelve pounds in two months, and weakness over the past four months.

O: Nontoxic appearing white female that appears consistent with her stated age of 61 years old. PERRLA at 3mm. Facial symmetry equal with no facial droop noted. The neck is supple and trachea is midline. The left thyroid is enlarged and tender to palpation. Bradycardic apical rate of 52 beats per minute with S1 and S2. No S3 or S4 noted. Hand grips strong and equal bilaterally. Radial pulses strong and equal bilaterally. Respirations are even and unlabored. Lungs clear to auscultation bilaterally. The abdomen is soft and non-tender. Bowel sounds present in all four quadrants. Skin is dry and flaking. Leg strength strong and equal bilaterally. Ambulates without difficulty or assistance. Pedal pulses present with no edema noted in lower extremities.

A: The patient may be suffering from hypothyroidism. Blood tests of thyroid stimulating hormone (TSH) and thyroxine (T4) levels are ordered. Normal values for TSH are 0.5-6 uU/ml, and normal T4 levels are 4.6-12 ug/dl (American Thyroid Association, 2012). Results show a high TSH level of 6.2 uU/ml and a low T4 level of 1.4 ug/dl. This indicates that the pituitary gland is releasing thyroid stimulating hormone, but the thyroid is not releasing thyroxine, which confirms that the thyroid gland is not functioning properly (American Thyroid Association, 2012).

P: This patient will most likely be referred to an endocrinologist for further testing, including a radioactive iodine uptake test and needle aspiration biopsy of the thyroid to rule out a malignant source of these symptoms. In the absence of a malignancy, she will probably be prescribed levothyroxine to increase her metabolism to counteract the decreased output of her thyroid. She should be instructed to self-check her pulse and seek medical attention if her bradycardia becomes symptomatic.

Although these patients do not exist, their symptoms and diagnoses are relatively common. Close attention to both subjective and objective data can assist the nurse in providing the proper care and teaching to promote favorable outcomes in either case.

References

American Thyroid Association. (2012). Thyroid Function Tests. Retrieved October 28, 2014, from

Thyroid Function Tests

Baylor College of Medicine. (2014). Eustachian Tube Dysfunction. Retrieved October 28, 2014, from

https://www.bcm.edu/healthcare/care-centers/otolaryngology/conditions/eustachian-tube-dysfunction

Jarvis, C. (2012). Physical Examination and Health Assessment [VitalSouce bookshelf version]. Retrieved from

http://digitalbookshelf.southuniversity.edu/books/978-1-4377-0151-7/outline/8

Medscape (2014). Amoxicillin (Rx) – Amoxil, Moxatag, more..Trimox. Retrieved October 28, 2014, from

http://reference.medscape.com/drug/amoxil-moxatag-amoxicillin-342473