Week5 Assessment Discussion: Nose Focused Exam
Identifyinginformation: A fifty years old male identified as Richard.
CC:Nasal congestion, sneezing, rhinorrhea, and postnasal drainage.
HPI:Richard has had an itchy nose, eyes, palate and ears for the lastfive days. The symptoms are worse in the evening hindering sleep. Therefore he has been taking over the counter Mucinex over the lasttwo days to help him sleep, although the impact has been minimal.
PMH:No childhood allergies or past medical record or history available.No psychiatric history. He is always alert and oriented. No familyhistory is known. He has been taking Mucinex for the last two days,in the evening.
PSH:No surgical history.
SH:Occupation or level of education of the patient not provided. Noknown history of drug abuse.
ROS:Redness and inflammation observed in the ears and throat. He keepspressing and rubbing his nose to the bridge using his fingers. Thepatient has pale and boggy boggy nasal mucosa with clear thinsecretions and enlarged nasal turbinates, which obstruct airway flowbut his lungs are clear. His tonsils are not enlarged but his throatis mildly erythematous. Other physical examination includesulceration, skin rushes, bleeding gums, chest pain and dry mouth.
Tests:Skin test, blood test, tomography CT scan, nasal endoscopy. The testswill be used to rule out other conditions such as allergic causes.
Healthhistory:History of childhood allergies, history of the condition, familyhealth history, history of drug abuse.
O:Appropriatelydressed and groomed gentle man.
A:Nonallergicrhinitis. The clinical presentation proposes a case of rhinitis. Thepale andboggyboggy nasal mucus and absence of past allergies as well as rednessand inflammation in the ear and through suggest a case on nonallergic rhinitis.
Differentialdiagnosis: The following conditions have similar symptoms but can beruled out through differential diagnosis. They include llergicrhinitis, sinusitis, gustatory rhinitis, conjunctivitis, influenza,rhinosinusitis, hormonal rhinitis, acute sinusitis, chronicsinusitis, sarcoidosis.
P:Flonase50mcg/spray, twice per day every nostril.
Patientadvised to discontinue the use of decongestant since it was found tobe less useful. Patient also advised to avoid environmental triggerssuch as smoke, although the condition is not as a result of allergicreaction.
Patientadvised to visit the health facility 2- 3 weeks later and immediatelyin case of worsening symptoms.
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