Case study assignment: assessing the head, eyes, ears, nose, and | NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning | Walden University




CASE STUDY 1: Focused Nose Exam 

Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and

postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for

5 days. As you check his ears and throat for redness and inflammation, you notice him

touch his fingers to the bridge of his nose to press and rub there. He says he’s taken

Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if

the Mucinex has helped at all, he sneers slightly and gestures that the improvement is

only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear

thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs

are clear. His tonsils are not enlarged but his throat is mildly erythematous.

The Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

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