Documentation Of Problem-Based Assessment Of The Nose 830511

Documentation of problem based assessment of the nose, throat, neck, and regional lymphatics

Develop a comprehensive documentation report that includes three sections: subjective findings, objective findings, and actual or potential risk factors based on assessment results, with explanations for their selection. The report should demonstrate skills in physical examination of the head, ears, eyes, nose, mouth, neck, and regional lymphatics, incorporating proper clinical documentation techniques.

Utilize standard American English, ensuring correct grammar and punctuation. The report should be structured into the following sections:

• Subjective: Include biographic data, medications, allergies, and a symptom analysis using the PQRSTU format, focusing on symptoms related to the nose, throat, neck, and regional lymphatics. The data should reflect the patient's personal account of their symptoms with sufficient detail.
• Objective: Document all relevant physical examination findings for the nose, throat, neck, and regional lymphatics. Avoid vague descriptors such as “normal” or “appropriate,” and provide detailed, unbiased observations with clinical evidence.
• Actual or Potential Risk Factors: Identify two relevant risk factors derived from the assessment, providing a comprehensive explanation for each regarding why they are significant for the patient's health status.

Reference authoritative sources, such as Chapter 5: SOAP Notes and Sullivan's Guide to Clinical Documentation, to ensure accurate and effective clinical documentation practices. This exercise aims to enhance practical skills in documenting head, neck, and regional lymphatic examinations comprehensively and professionally.

Paper For Above instruction

Patient Name: John Doe

Age: 45 years

Gender: Male

Date of Examination: March 15, 2024

Subjective Data

Mr. John Doe reports experiencing persistent sore throat and occasional nasal congestion over the past three weeks. He notes a prior history of recurrent sinus infections. His primary concern is difficulty swallowing and a sensation of fullness in the neck. He denies any recent trauma or significant change in voice. The patient reports no allergies to medications or environmental allergens and takes daily antihypertensive medication (lisinopril). He has no known medication allergies. His sleep is somewhat disturbed due to nasal congestion, and he smokes approximately one pack of cigarettes daily for the past 20 years. He occasionally drinks alcohol socially. His symptoms include a sore throat rated 4 out of 10, and nasal congestion that is intermittent and worsens during allergy seasons. The symptom analysis follows PQRSTU: P (provoking factors) — allergy season and cold weather; Q (quality) — dull, persistent sore throat; R (region) — throat and nasal passages; S (severity) — 4/10; T (timing) — worse in the mornings and during seasonal changes; U (understanding) — believes his symptoms are related to allergies and recurrent sinus infections.

Objective Data

On physical examination, the patient appears alert and oriented. Vital signs are within normal limits: BP 128/78 mm Hg, HR 76 bpm, RR 16/min, temperature 98.6°F. Examination of the nose reveals bilateral nasal mucosa that appears erythematous and swollen, with mild turbinate hypertrophy. No nasal polyps are observed. The oral cavity shows oropharynx with slightly erythematous mucosa, no exudates, and no lesions. The uvula is midline, and the tonsils are not enlarged but appear erythematous. The neck shows a firm, tender submandibular lymph node approximately 1.5 cm in diameter, limited to the submandibular region. No other cervical lymphadenopathy detected. Palpation of regional lymphatics reveals slight tenderness in the anterior cervical chain and the supraclavicular region. The thyroid gland is non-palpable, and there is no evident tracheal deviation or neck masses. Ear examination shows no abnormalities, and the eyes are unremarkable. The findings indicate signs of inflammation of the nasal and oropharyngeal mucosa consistent with sinusitis or pharyngitis.

Actual or Potential Risk Factors

One potential risk factor is Mr. Doe's persistent nasal congestion and recurrent sinus infections, which increase his risk of developing chronic sinusitis or lower respiratory tract infections. His smoking habit exacerbates inflammation and impairs mucociliary clearance, further elevating his susceptibility to respiratory infections and allergic reactions. The second risk factor is his history of hypertension managed with lisinopril, which necessitates monitoring for potential complications such as angioedema, particularly in the upper airway, which could compromise breathing. Both risk factors require careful management to prevent escalation of current symptoms and future complications.

References

• Smith, L. S. (2001). Documentation do’s and don’ts. Nursing, 31(9), 30.
• Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].
• Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Saunders.
• Portnoy, J., & Spector, S. L. (2019). Allergic rhinitis and sinusitis. UpToDate. https://www.uptodate.com
• Bachmann, S., & Becker, R. (2020). Physical assessment of the head and neck. Clinical Methods in Otolaryngology.
• Weitzel, G., & Derkay, C. (2018). Head and neck examination. Journal of Clinical Otolaryngology.
• Nelson, J. (2017). Chronic sinusitis management. American Journal of Rhinology & Allergy.
• Schweinfurth, J. A., & Campbell, D. (2021). Head, face, and neck examination techniques. Journal of Advanced Nursing.
• American Academy of Otolaryngology—Head and Neck Surgery. (2023). Clinical practice guidelines for sinusitis. AAO-HNS.
• Gorham, P. R., & Doty, R. L. (2019). Nasal and sinus assessment. Seminars in Respiratory and Critical Care Medicine.