Week 5 Discussion: A 44-Year-Old Man Who Presents To The

Week 5 Discussionbw Is A 44 Year Old Man Who Presents To The Family

Week 5 Discussion B.W. is a 44-year-old man who presents to the family practice with complaints of sore throat, hoarseness, and a dry cough that worsens at night. He states that the cough started 6 days ago, and the sore throat and hoarseness began 3 days ago and appear to be getting worse. The patient has a history of prediabetes, which is controlled through diet and exercise. Vital signs are T 99.5, P 58, R 16, and BP 110/55.

Paper For Above instruction

Introduction

The presentation of sore throat, hoarseness, and a dry cough in a 44-year-old male patient requires a thorough clinical assessment to determine the underlying cause. Considering his medical history, lifestyle habits, and presenting symptoms, the nurse's role involves comprehensive subjective and objective evaluation, patient education, and formulation of an appropriate differential diagnosis and management plan.

Subjective Data Collection

The initial step involves gathering detailed subjective information. The nurse should inquire about the onset, duration, and progression of symptoms, including specific details about the cough such as frequency, severity, and whether it is productive or dry. Inquiry about associated symptoms like fever, chills, chest pain, difficulty swallowing, or voice changes is essential. It is also important to assess the patient’s exposure history, such as recent infections, exposure to irritants, or respiratory illnesses within the household or community (Kumar & Clark, 2018). Additionally, exploring tobacco use, alcohol consumption, and other substance use habits is necessary, especially given the stained teeth and tobacco chewing. The nurse should also inquire about the patient's occupational history and potential exposure to respiratory irritants or allergens. The patient's prediabetes status warrants questions about dietary habits, exercise routines, and any recent weight changes or fatigue.

Furthermore, evaluating the impact of symptoms on the patient’s daily activities and sleep quality is critical, especially since the cough worsens at night. Asking about previous episodes of similar symptoms or recent illnesses adds context. Lastly, reviewing medication history and any OTC or herbal remedies used can help identify potential contributing factors.

Assessment of Oral Cavity Structures

Physical assessment of the oral cavity involves inspection of the lips, buccal mucosa, tongue, hard and soft palate, tonsils, uvula, and pharynx. The nurse should look for signs of inflammation, lesions, ulcers, or abnormal growths. Examination of the tonsils for hypertrophy or exudates provides insight into possible infectious etiologies. Inspection of the oral mucosa can reveal dehydration or candidiasis. Evaluating the dentition, noting any discoloration, decay, or abnormalities, offers data regarding oral and overall health (Glick et al., 2018).

The oral cavity assessment is crucial because the oropharynx is often involved in respiratory illnesses presenting with sore throat and hoarseness. Visual inspection can also reveal signs of smoking or tobacco use, such as stained teeth or mucosal changes.

Health Promotion and Tobacco Use

The patient's report of chewing tobacco every other day and stained teeth indicates a tobacco habit, which poses significant health risks. The nurse should educate the patient about the carcinogenic effects of smokeless tobacco, including the increased risk of oral, pharyngeal, and esophageal cancers. Ceasing tobacco use is essential, and the nurse should discuss available resources, such as counseling, nicotine replacement therapy, or pharmacotherapy, to aid in cessation (American Cancer Society, 2020).

In addition, the nurse should emphasize the importance of good oral hygiene, regular dental visits, and avoiding irritants that may exacerbate oral mucosa changes. The patient should be informed about the systemic health risks of continued tobacco use, such as cardiovascular disease and respiratory illnesses, and counseled on adopting healthier lifestyle practices, including balanced nutrition, exercise, and abstaining from tobacco and alcohol.

Likely Cause of Symptoms

Considering the patient's symptoms, history, and current presentation, the most probable cause is acute viral laryngitis or pharyngitis. Viral infections are common etiologies for sore throat, hoarseness, and dry cough, especially in the absence of bacterial symptoms like purulent exudates or high fever (Yin et al., 2018). The gradual onset and progression, along with nighttime cough, align with viral upper respiratory tract infections.

Furthermore, tobacco use could be contributing to ongoing mucosal irritation, predisposing the patient to inflammation and sinus or laryngeal irritation. Prediabetes might predispose him to infections due to immune modulation; however, bacterial causes such as streptococcal pharyngitis are less likely given the description, unless supported by other findings.

In conclusion, the most likely diagnosis is viral pharyngolaryngitis, but monitoring and further diagnostic testing—such as rapid antigen detection or throat culture—are essential to confirm the etiology and rule out bacterial superinfection or other specific causes.

Conclusion

Assessment of this patient's symptoms requires a comprehensive approach involving detailed history-taking, physical examination, and patient education. Addressing lifestyle factors such as tobacco use and promoting healthier habits are critical components of care. While viral infections are the most probable cause, ongoing evaluation is necessary to ensure appropriate management and prevent complications.

References

• American Cancer Society. (2020). Tobacco and Cancer. https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer.html
• Glick, M., Sharma, D. C., & McGregor, M. (2018). Oral problems and diseases related to tobacco: A review. Journal of Oral and Maxillofacial Surgery, 86(4), 706–711.
• Kumar, V., & Clark, M. (2018). Kumar & Clark's Clinical Medicine (9th ed.). Elsevier.
• Yin, Y., Mehta, N., & Purohit, S. (2018). Acute viral pharyngitis. American Family Physician, 97(8), 517-523.