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, and submit this in a Word document to the drop box provided. ApA format  please reference

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

Introduction

This paper presents a comprehensive history and assessment of a nose, mouth, throat, or neck problem. The purpose of this assignment is to analyze the subjective and objective findings of a specific case, identify any actual or potential risks, and document the assessment in APA format.

Subjective Findings

In order to gather subjective information, it is essential to conduct a thorough interview with the patient or gather information from available sources such as medical records or referral letters. The subjective findings provide crucial insights into the patient’s symptoms, medical history, lifestyle, and any previous interventions. For the purpose of this assignment, the case study discusses a patient presenting with chronic nasal congestion.

The patient, a 42-year-old male, reports frequent episodes of nasal congestion for the past six months. He describes the congestion as persistent, bilateral, and accompanied by occasional sneezing. The patient reports that the nasal obstruction worsens in the evening and during cold weather. He denies any associated symptoms such as nasal discharge, postnasal drip, or loss of smell. The patient also denies experiencing any pain, headaches, or changes in vision.

Upon further inquiry, the patient reveals a medical history significant for seasonal allergies and a prior diagnosis of allergic rhinitis. He reports a family history of allergies and asthma. The patient mentions that he has tried over-the-counter nasal decongestants intermittently with temporary relief but no long-lasting improvement.

The patient denies any past surgical interventions or trauma to the nose, mouth, throat, or neck. He reports not taking any prescription medications and states that he leads a healthy lifestyle, exercising regularly and having a balanced diet. Additionally, the patient denies smoking or alcohol use and has not experienced any recent illnesses or significant weight changes.

Objective Findings

Following the subjective assessment, a comprehensive objective assessment is performed to collect data through physical examination and diagnostic tests. The objective findings help in formulating a differential diagnosis and determining appropriate interventions.

The physical examination includes inspection, palpation, percussion, and auscultation of the nose, mouth, throat, and neck regions. The examination of the nose reveals external symmetry, absence of deformities or scars, and patent nares. The nasal mucosa appears pink and intact, without visible signs of inflammation or polyps. No nasal discharge is observed or reported by the patient. Palpation of the sinuses does not elicit any tenderness or pain.

Examination of the oral cavity reveals moist mucosa, intact teeth, and pink gums. No lesions, ulcers, or masses are noted. The throat examination shows a midline uvula, bilateral tonsils within normal size, and absence of exudates or erythema. The posterior pharyngeal wall appears smooth and pink. The neck examination demonstrates symmetrical range of motion without pain, palpable lymph nodes, or masses.

Diagnostic tests such as a complete blood count (CBC), allergy testing, and nasal endoscopy may be indicated to further evaluate the condition. However, for the purpose of this assignment, the focus is primarily on the subjective and objective findings.

Actual or Potential Risks

Based on the information obtained, several actual or potential risks can be identified. The primary concern is the chronic nasal congestion that considerably impairs the patient’s quality of life. The persistence of symptoms despite over-the-counter interventions suggests the presence of an underlying condition that requires further evaluation and appropriate treatment. The patient’s medical history of seasonal allergies and allergic rhinitis also suggests an allergic component to the nasal congestion. This could lead to potential complications such as sinusitis or recurrent upper respiratory infections if left untreated.

Conclusion

The history and assessment of a nose, mouth, throat, or neck problem provide valuable insights into the patient’s subjective and objective findings. In this case, a 42-year-old male with chronic nasal congestion and a history of allergic rhinitis was evaluated. The examination of the nose, mouth, throat, and neck regions revealed no significant abnormalities or signs of inflammation. The primary concern is the persistent nasal congestion, and further evaluation is required to determine the underlying cause and implement appropriate interventions to alleviate the symptoms.