Health Assessment

Health Assessment


I will use the OLDCARTS technique to gather more information about the chief complaints that each patient has. I will enquire of the nature of pain in the throat to determine whether it is burning, stabbing or dull pain.  I will ask Mary whether she has tried any therapies to alleviate the pain in the throat. I will also enquire about the relieving factors for a sore throat. The most probable cause of a sore throat for Mary is a common cold. A common cold is the most prevalent viral infection which is easily separated from one person to another and leads to the inflammation of the throat (Dhingra & Dhingra, 2014). Given that one of the children was suffering from common cold just recently she could have also infected the mother.

I will inspect Mary’s throat to evaluate for signs of inflammation such as reddening of the throat. I will also check for oedema which occurs as a result of inflammation of the throat. I will also palpate to determine whether tonsillar lymph nodes around the throat are swollen in an aftermath of the infection which could worsen difficulty swallowing. The primary lab test which I can order for Mary is a throat swab for culture and sensitivity (Dhingra & Dhingra, 2014). The test will establish the causative agent and drugs that can be used in the management of the patient.


I will ask Mary if she tried any drugs for the children when they complained of pain or any other remedies tried. I will ask Tommy about what makes the pain in the ear reduce and what increases it (aggravating and alleviating factors). I will also ask him to rate the pain using the fingers scale to determine the intensity of the pain. The main differential diagnosis for Tommy is otitis externa. Otitis externa is characterized by pain which is aggravated by pulling of the earlobe (Wilson, 2013). Tommy complains that his ear is too painful to touch hence it could be otitis externa. I will inspect the ear to determine the location of the infection whether it is in the middle or external ear. I will also look out for signs of inflammation inside the ear. I will also determine whether there is any discharge in the ear. I can send a sample of some of the fluid in the ear if there is any accumulation of discharge.


I will to ask about the characteristics of the pain and any other accompanying symptoms. I will also ask about any factors that reduce the pain and those that worsen the pain. I will also enquire if Mary has tried any therapies to reduce the pain. I will enquire on other symptoms such as nausea and discharge to establish a diagnosis. The most probable cause of the ear pain for Paddy is otitis media. He complains that the pain is too intense and had a history of cold. Common cold increases the risk of spread of infection from the throat to the middle ear (Ellis, 2013). The feeling of ears popping and fluffy is a common characteristic of otitis media. I will inspect Paddy’s ear to determine the exact location of the infection. I will check for signs of inflammation such as redness and swelling. I will also evaluate whether there are any abnormal discharge from the ear which may result from the ear infection. I can send a sample of the abnormal discharge to the lab for culture and sensitivity.






Dhingra, P. L., & Dhingra, S. (2014). Diseases of Ear, Nose and Throat-E-Book. Elsevier Health Sciences.

Ellis, M. (Ed.). (2013). Modern Trends in Diseases of the Ear, Nose and Throat: Modern Trends Series. Butterworth-Heinemann.

Wilson, T. G. (2013). Diseases of the ear, nose, and throat in children. Butterworth-Heinemann.

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