Running head: ASSESSMENT OF HEAD, NECK, EYES, EARS, NOSE, AND THROAT 1

Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

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Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

Symptoms that affect the throat, nose, ears, eyes, neck, and head can be related to injuries,

infection, structural abnormalities, or serious underlying health problems. As manifestations

that occur in this body region can be vague, a focus examination that includes diagnostic tests

may be needed to obtain accurate, relevant information to identify the health problem

correctly. The purpose of this week’s discussion will explore how to assess the throat, nose,

ears, eyes, neck, and head to form an accurate diagnosis. The format of focused SOAP note

will be utilized for the assigned case study which involves symptoms needing further

assessment of the throat.

Episodic/Focused SOAP Note for Throat Exam

Case study:

“Chantal who is aged a 32-year-old female comes into your office with complaints of

“feeling tired” and “hair falling out”. She has gained 30 pounds in the last year but notes

markedly decreased appetite. On ROS, she reports not sleeping well and feels cold all the

time. She is still able to enjoy her hobbies and does not believe that she is depressed.”

Patient Initials: Chantal    Age: 32                     Gender: Female

Subjective:

Chief Complaint (CC): feeling tired” and “hair falling out.” 

History of Present Illness (HPI):  Chantal is alert and oriented, comes in the clinic with 3

days of feeling tired” and “hair falling out.” She has gained 30 pounds in the last year but

notes markedly decreased appetite. The client says she feels cold all the time of nasal

congestion, postnasal drainage, and rhinorrhea and not sleeping well. She also complains of

sneezing with itchy eyes, ears, nose, and palate. Upon observation, she uses his fingers to

touch and rub the bridge of his nose. She has been taking OTC Mucinex at HS to help her
ASSESSMENT OF HEAD, NECK, EYES, EARS, NOSE, AND THROAT 3

breathe without good results. No enlargement of the tonsils, throat appears mildly

erythematous. 

Medications:  Lisinopril 20mg PO QD; Mucinex OTC QHS PRN. 

Allergies: NKDA

Past Medical History (PMH): HTN

Past Surgical History (PSH): Pins placed in the ankle after MVA 2005

Sexual/Reproductive History:  Heterosexual, sexually active. Married, 2 children, one still

living at home

Personal/Social History: Denies drinking alcohol, smoking, or drug abuse

Immunization History:  flu vaccine 2016; Pneumonia vaccine winter 2015

Significant Family History: Lives with her husband, her married daughter and her family.

Review of Systems: 

General: she reports not sleeping well and feels cold all the time. She is still able to enjoy

her hobbies and does not believe that she is depressed. She has gained 30 pounds in the last

year but notes markedly decreased appetite.

HEENT: 

Nose: Clear nasal drainage, itchy eyes, nasal congestion, sneezing, and ears x 5 days. 

Eyes: Denies changes in hearing or vision other than itchiness and watery eyes. Wears

glasses for farsightedness. No history of cataracts, glaucoma, diplopia or photophobia.

Ears: Ears normal bilaterally, no drainage, no recent ear infections. Denies any recent sinus

infection, smell intact. 

Mouth: No noted halitosis or dental caries observed. Denies difficulty chewing or

swallowing. Erythema of the throat.

Neck: Denied pain, no masses, no lymphadenopathy.

Respiratory: Denies SOB, coughing, sputum production, and lungs clear.

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CV: Denied chest pain, palpitations. No history of arrhythmia. Takes Lisinopril for HTN.

Gastrointestinal: No change in bowel habits. No nausea, vomiting, diarrhea, or constipation.

GU: Denies dysuria, incontinence, hesitancy, frequency or other abnormalities when voiding.

Skin: No open wounds or lacerations. No rashes, itching, bruising.      

MS: History of traumatic, full ROM in all extremities ankle fracture on right.

Psych: Denies depression or anxiety. Normal affect. 

Neuro: Denies migraines, seizures, or falls.

OBJECTIVE:

Physical Exam  

Vital signs: BP 126/70 R arm, P 76, RR 16, T 97.9 oral, Wt. 212# Ht. 5’11”

General: clean, appears fatigued; alert & oriented x 3.

HEENT: PERRLA, Wears glasses for reading.  Reports lack smell and taste, which is

new. Tonsils normal. Denies oral abnormalities, throat is erythematous. Denies vision or

hearing changes.

Neck: No tenderness with palpitation, no abnormalities noted.

Chest/lungs: CTA bilaterally

Heart/peripheral vascular: pulses strong and regular in all four extremities. No murmur

noted, no irregular heartbeat noted.

Abdomen: no abnormalities noted, hyperactive bowel sounds in all four quadrants. 

Genital/Rectal: Not assessed 

Skin: pale, warm, dry.

Musculoskeletal: no abnormalities noted

ASSESSMENT:

Lab Tests/Exams and Results:

CBC-WNL
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Flu Swab-Negative

Rapid Strep-Negative

Differential Diagnosis (DDx):

1. Acute sinusitis- Infection, usually bacterial, of one or all of the paranasal sinuses

(Petersen, 2016). Some of the symptoms are loss of smell, facial pain, postnasal drip,

anterior discharge, nasal obstruction (Petersen, 2016). The sinus does not

transilluminate (Petersen, 2016). 

2. Rhinovirus – according to Ball et al (2015), the disease is mostly associated with

sinus infections, sore throats, and the common cold. The rhinovirus can also cause

symptoms of sneezing, congestion, breathing difficulties, runny nose, and cough

accompanies by loss of appetite, headache, weakness, fatigue, and muscle aches

(Petersen, 2016). 

3. Allergic rhinitis- When the body is exposed to specific allergens, hay fever or allergic

rhinitis occurs as an inflammatory response or reaction (Ball et al., 2015). Pollen is

one of the most common allergens that cause allergic rhinitis. The symptoms can be

uncomfortable and include runny nose, sneezing, and itchy, watery eyes (Petersen,

2016). An “allergic salute” is a physical sign described as “the characteristic gesture

of a person with allergic rhinitis: rubbing his or her nose with the index finger” (Ball

et al., 2015). Dark coloring around the eyes is another physical sign and is related to

nasal congestion or vasodilation (Petersen, 2016). 

4. Chronic Sinusitis- A common condition of inflammation and swelling of nasal

cavities and passages that linger for at least eight weeks without relief from treatment

(Petersen, 2016). The client who has this condition experience breathing difficulties

because the nose has been blocked by mucus builds up interfering with drainage. You

may have painful or swollen eyes which may cause headaches or facial pain
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(Hamilos, 2000). Symptoms of chronic sinusitis are less apparent and may include

blockage or congestion of the nasal cavity, post-nasal drainage, reduced sense of

smell, and fatigue (Hamilos, 2000). Sinus radiography indicates filled sinus cavities

(Hamilos, 2000).

Plan: 

1. Education on certain allergens that may trigger symptoms, such as dust mites and pollen.

2. Daily oral antihistamine that also contains a decongestant and does not interfere with his

HTN or medication he takes for his HTN (Lisinopril). Usually, antihistamines do not interact

with Lisinopril but Richard should be told to monitor his blood pressure when starting the

allergy medication.

3. Immunotherapy if severe or consult to an allergist for further work-up.

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References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s

guide to physical examination. St. Louis, MO.

Hamilos, D. L. (2000). Chronic sinusitis. Journal of Allergy and Clinical

Immunology, 106(2), 213-227.

Petersen, S. W. (2016). Advanced health assessment and diagnostic reasoning. Jones &

Bartlett Learning.