Assessing the ears, nose, and throat

Assessing the ears, nose, and throat

Patient information
Lily is a 20yrs old American lady who is currently studying at the community college
Subjective data
Chief Complain: Lily visits the clinic with chief complains of sore throat, decreased appetite,
pain in swallowing, and headaches.
HPI: she is a young student who explains that she has heard rumors of flu-like symptoms within
their institution. She further adds that she has had a sore throat for three days which is mild and
the reason for visiting the hospital is due to the alleged outbreak. Additionally, she explains that
she feels a slight headache which just started recently, decreased appetite which also started two
days ago, and she explains that she feels pain when swallowing food or anything. All the
symptoms experienced are moderate and started two or three days ago. She explains that the pain
is moderate though is increasingly becoming more painful which results to the problems with
feeding. She exclaims the pain is around the throat and radiates within the throat region
Current medication: she explains that she bought some diclofenac over the counter and she has
been using them to manage the pain for the past few days. Oral diclofenac 50mg, BD.
Allergies: lily has no known allergy to food though she does not consume red meat. She has
never experienced any reaction to medication.
PMH: during her childhood she received all her immunizations according to vaccination
program. However, she sometimes experienced sore throats while growing up which her mother
managed with some antibiotics. She has no history of admission in the hospital and she has never
been transfused.

Social history: Lily is not a smoker and does not drink alcohol. She enjoys playing badminton as
she is the captain in her school and also enjoys attending choir and church meetings when free.
Family history: she has no history of chronic illness but her mother is hypertensive and has been
on management since she was 40yrs. She is the 2 nd born in a family of three and all kins are alive
and well. She lives with her parents in their three bedroomed apartment with the mother being a
secretary and the father works in the textile manufacturers. Even her younger brother
experienced some of the symptoms related to hers occasionally as the mother underwent
tonsillectomy when she was young.
Review of systems
Head: no form of dizziness, she has a slight headache
Eye: no visual disorders, no squinted eyes, no blurred eyes, and the patient doesn’t wear glasses.
Ear: negative for hearing problems, no hearing aids, no discharge and no redness or pain.
Nose and sinus: no obstruction, no bleeding, no nasal congestion or running nose, and no pain.
Mouth and throat: positive for bad odor, no dentures, no history of dental caries, no cavities and
no tooth eruptions. No speech problems, some swelling of the tonsillar glands, and she has
difficulty in swallowing.
Neck and lymph: there is some swelling of lymph nodes and the thyroid glands. No pain, lumps,
or stiffness.
Cardiovascular and hematology: negative for syncope, dyspnea, no palpitations, and no cyanosis.
No edema of the limbs and cold extrimities. No heart murmurs, no history of hypertension or

Pulmonary: There is no chest pain; there is no chest congestion, no shortness of breath, no
wheezing, no coughing, no sputum production, no bronchitis or emphysema, no presence of lung
diseases and allergy.
Gastroenterology: no vomiting, no nausea, no diarrhea. There is history of constipation. There
are regular bowel movements with normal appetite. Weight reduction of 15kgs noted. Some pain
noted on the lower abdomen.
Genitourinary: no swelling or pain. No difficulty in urination or pain when urinating. No
incontinence, no frequent urination, no blood in urine, no decreased urine stream, no signs of
UTI, no stones, and no urgency to urinate. No form of discharge.
Dermatological: No rashes or itchiness, no swelling, no changes in skin color, and no changes in
hair and the nails.
Musculoskeletal: No pain or swelling, there is no stiffness, no decreased joint movement, no
broken bones, no sprains, no arthritis, and no gout.
Neurological: no dizziness, no headaches, no seizures, and no head injury. No learning
disabilities, no hyperactivity, and no decreased attention span.
Psychiatric: no changes in mood or affect.
Objective data
Vital statistics:
Temperature Oral 36.8 degC
Peripheral Pulse Rate 68 bpm
Pulse location Brachial
Respiratory rate 20 brth/min
Oxygen saturation 98 %


Oxygen Room Air
Blood pressure location/view Right Arm
Blood pressure systolic 129 mmHg
Blood pressure diastolic 75 mmHg
Mean Arterial Pressure, Cuff 93 mmHg
General appearance: neat, tidy, and well kempt.
Head: The head is normo-cephalic with clean and tidy hair, scalp is uniform with no lacerations.
On the temporal mandibular joint, there is no swelling, clicking bilaterally, any redness, and
snapping. The joint has full ROM and there is sinus tenderness on the maxillar. The skin on the
face is uniformly colored, has no rashes, and normal sized.
Eye: Bilaterally located at one thirds of the face, they are uniformly colored with optimal
functionality. Eyelids intact, with normal skin color, the eyelashes point outwards from the eyes,
and no swelling or inflammation along the edges. Both sebaceous glands located near the hair
follicles. The cornea is clear with no exudates. Has blue iris with a clear, white sclera that is free
of jaundice. The conjunctiva is clear with no redness and swelling. The visual acuity is normal,
20/20 ion both eyes. Both pupils respond appropriately to light and accommodation. The
extraocular muscles are present with normal range of motion.
Ear: The tympanic membrane is intact with no lesions and with proper drainage. Scanty amounts
of wax visualized with good hearing acuity based on the webers test. Hearing is intact bilaterally.
Nose: The nasal nares are patent with the septum located at midline, the mucous membrane
moist with no discharge from the nose.

Mouth: The lips are pink and moist with a moist mucous lining, no lesions, ulcerations, though
she has oral odor. The gums are pink with clearly defined margins. Tongue is located at the
midline with a rough anterior surface and a smooth posterior surface. She has a total of 31 teeth
with one premolar missing from the lower jaw. The throat is moist with both tonsilar glands
present and pink in color.
Neck: No swelling of the lymph nodes. The thyroid glands are not palpable. The trachea is
located at the midline.
Inspection: the chest is symmetrical, without any scars. There is no presence of cardiac heaves.
There is uniform and symmetrical expansion and relaxation of the chest with respirations. No
other chest wall motions detected.
Palpation: on palpation no thrills appreciated. The point of maximal impulse is noted at mid-
clavicular line, over the left lateral flank in fifth inter-costal space.
Auscultation: the normal S1 and S2 sounds heard, dub and dap which are accompanied with a
regular heart rate and heart rhythm. S2 is greater than S1 at the base whereas S1 is greater than
S2 at apex. No abnormal heart sounds detected like murmurs, friction rubs, or splitting of the
heart sounds heard.
Maneuvers: when standing or squatting, there are no murmurs heard. With the valsava maneuver,
there is no sound heard when standing or during release of the valsalva strain.
Chest: On inspection, there are no swellings or scars present. There is bilateral chest movement
when the patient is breathing. There is no use of accessory muscles in respiration and no
adventitious sound crackles note. On percussion there is resonance bilaterally. On palpation,
chest wall is smooth with no swelling.

Abdominal: abdominal symmetry with no swelling or organomegally. No scars noted and the
location of the umbilicus is midline according to inspection. The stomach is non-tender, non-
distended, with no enlarged liver on palpation. Bowel sounds present in all the four quadrants
with tympany in left upper quadrant and the right and left lower quadrants. Dullness is heard at
the left upper quadrant over the liver.
Musculoskeletal: There is good muscle tone and strength which is equal and symmetrical. There
is normal position, alignment, and mobility of whole parts and limbs with no deformity noted.
Resistance of motion tested on all four limbs indicating perfect motor control. Sensory: Grossly
normal to touch and response to a pin prick. Cerebellar: there is no tremor nor dysmetria and
reflexes symmetrical 1+ throughout, absence of the Babinski sign.
CNS: The patient is alert and cognitive oriented to time, place, and person. Cranial nerves I and
II intact with full visual acuity. Cranial nerves III, IV, and V intact when tested with extraocular
muscle movement. Eyes move appropriately according to the field of gaze. For nerve V, the
patient is able to bite and clench teeth. For cranial nerve VII facial expressions such as smiling
are expressed appropriately. Cranial nerve 8 intact as the patient can hear properly bilaterally.
Patient’s cough and gag reflex present for cranial nerve XI. Cranial nerve X, the uvula is
midline, and palate moves upwards with CN XI shoulder movement is uniform bilaterally. CN
XII the tongue is medial and able to move sideways.
Genitourinary: normal male genitalia present with no swelling or pain. There is no discharge
from the urethra and its patent.
Skin: Skin is warm, with uniform color, no rashes present, and no jaundice.
Mental status: There is appropriate affect and mood. Lily is alert and very cooperative.


Diagnostic results
A throat swab is obtained by the doctor through rubbing of a sterile swab from the throat to
acquire some secretions for bacterial culturing. A complete cell count is obtained through
laboratory testing to help identify the type cells that are elevated in the blood. That enables the
doctor to determine of the infection is viral or bacterial. A comprehensive physical examination
may be used to identify the actual illness in infections affecting the ear, nose, and throat.
Actual diagnosis: tonsillitis
Tonsillitis is an infection of the tonsillar glands which are small oval shaped pads of
tissue at the back of the throat thus resulting to inflammation (Farooqi et al.,2017). The most
common symptoms of tonsillitis include swollen tonsil glands, difficulty in swallowing, a sore
throat, tender and swollen lymph nodes, and headache.
Differential diagnosis
Epiglottitis is a life threatening condition that is caused by infection of the epiglottis that
is responsible for the protection of the airway. The swelling of the cartilage results to blockage of
the airway. Infections or physical trauma are the most common causes of the condition
(Richardson et al.,2018). Just like tonsillitis, some of the common conditions include; a severe
sore throat, difficulty or painful swallowing, and difficulty in breathing. However, in epiglottitis,
there is change in voice and speech and breathing sounds.
Retropharyngeal abscess
The retropharyngeal space is the one that is located posterior to the pharynx that is bound
by the buccopharyngeal fascia anteriorly. An abscess is a swelling located at the space and is

commonly associated with infections mostly from streptococci and staphylococcus bacteria
(Bochner & Gangar 2017). It can result to mortality due to airway obstruction. Just like
tonsillitis, the common symptoms include a sore throat, difficulty in swallowing, and neckpain.
However, the illness is associated with difficulty in breathing, neck stiffness, and stridor.
Diphtheria is a serious bacterial infection that affects the mucous lining of the nose and
the throat. The signs and symptoms begin after 3 to 5days of infection and may include sore
throat, swollen glands, nasal discharge, and difficulty in swallowing (McMillan et al.,2017).
However, the main distinctive characteristic is difficulty in breathing and a rapid breathing rate.
Mononucleosis is a group of symptoms that are associated with Epstein Barr Virus and
commonly affect the young youth and adolescents. It is spread through saliva hence known as
the kissing disease. Some of the common symptoms include a sore throat, headache, swollen
tonsil glands, and fatigue (Kaul et al.,2018). However, the illness is systemic and results in
muscle weakness and occasionally, spleen or liver swelling.
Peritonsillar abscess
Peritonsillar abscess is a condition that develops as a complication of untreated tonsillitis
or strep throat. It is a condition characterised by a pus filled pocket developing next to one of the
tonsil glands (Chang et al.,2016). The symptoms include difficulty in swallowing, a sore throat,
bad breathe, and headache. However, what differentiates the illness from tonsillitis is the
swelling of the face or neck and a muffled voice.



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Chang, B. A., Thamboo, A., Burton, M. J., Diamond, C., & Nunez, D. A. (2016). Needle
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