You will perform a history of a nose, mouth, throat, or neck problem that your instructor has provided you or one that you have experienced, and you will perform an assessment including nose, mouth, throat, and neck. You will document your subjective and objective findings, identify actual or potential risks, CHECK FILE UPLOADED

The History and Assessment of a Nose, Mouth, Throat, or Neck Problem

Introduction

The nose, mouth, throat, and neck play a crucial role in various functions of the human body, including respiration, speech production, and swallowing. As a student, I have been assigned to perform a history and assessment of a problem related to one of these areas. In this assignment, I will document my subjective and objective findings, identify actual or potential risks, and propose appropriate interventions.

Subjective Findings

To begin the assessment, I will gather subjective information from the patient. This information will help me understand the patient’s symptoms, medical history, and any relevant factors that may contribute to the problem. For the purpose of this assignment, I will assume the role of a highly knowledgeable student and provide a detailed description of a common problem such as chronic rhinosinusitis.

Chronic rhinosinusitis is a condition characterized by inflammation of the nasal and sinus passages for a duration of at least 12 weeks (Fokkens et al., 2020). The symptoms typically include nasal congestion, facial pain, headaches, postnasal drip, and reduced sense of smell (Hamilos, 2017). Patients may also have a history of recurrent or persistent upper respiratory tract infections.

In this case, the patient is a 40-year-old male who has been experiencing chronic rhinosinusitis symptoms for the past six months. He reports having a persistent stuffy nose, which is worse in the morning and gets better throughout the day. He also complains of pressure and pain in his forehead and cheeks. The patient states that he often wakes up with headaches and has noticed a decrease in his sense of smell. He denies any fever or significant nasal discharge.

Furthermore, the patient mentions a history of seasonal allergies and occasional episodes of acute sinusitis. He has tried over-the-counter nasal decongestants and antihistamines in the past, but they provided only temporary relief. He has not received any previous medical treatment or interventions for his chronic rhinosinusitis.

Objective Findings

After gathering subjective information, I will proceed with the objective assessment of the nose, mouth, throat, and neck. This examination aims to identify any visible abnormalities, signs of inflammation, or structural variations that may contribute to the patient’s symptoms.

On inspection, the patient’s nose appears slightly swollen and congested. Nasal discharge is absent, and the septum appears midline. Palpation reveals mild tenderness and pressure over the frontal and maxillary sinuses. A transillumination test is performed, and bilateral sinus shadows are observed. The oral cavity is moist, and the uvula is midline. There is no tonsillar hypertrophy or exudate present.

Additionally, I will assess the patient’s neck for any signs of lymphadenopathy or abnormal masses. The neck is supple with no palpable lymph nodes or other abnormalities detected. The thyroid gland is non-palpable. There are no visible swellings or masses in the neck region.

Actual or Potential Risks

Based on the subjective and objective findings, I will now identify actual or potential risks associated with the patient’s chronic rhinosinusitis. By assessing the risks, I can provide appropriate interventions and recommendations to manage the condition effectively.

One actual risk identified in this case is the long duration of symptoms, exceeding the typical 12-week threshold for chronic rhinosinusitis. Prolonged inflammation can lead to complications, such as the development of nasal polyps or the spread of infection to surrounding structures (Hamilos, 2017). Since the patient has not received previous medical treatment, the risk of exacerbation and symptom progression is significant.

Another potential risk is the impact of chronic rhinosinusitis on the patient’s quality of life. The persistent nasal congestion, facial pain, and reduced sense of smell can affect daily activities, sleep, and overall well-being (Fokkens et al., 2020). Furthermore, the patient’s history of seasonal allergies and possible triggers may contribute to recurrent episodes of sinusitis or exacerbate the existing symptoms.

Conclusion

In conclusion, the history and assessment of a nose, mouth, throat, or neck problem require a comprehensive approach to gather subjective and objective information, identify risks, and propose appropriate interventions. In this assignment, I documented the history and findings related to chronic rhinosinusitis, including the patient’s subjective symptoms and objective examination results. The actual risks identified were the prolonged duration of symptoms and the potential impact on the patient’s quality of life. The next steps would involve discussing the findings with a healthcare professional and formulating a management plan tailored to the individual’s needs.