Discussion: Diagnosing HEENT Disorders

Discussion: Diagnosing HEENT Disorders

Discussion: Diagnosing HEENT Disorders

In clinical settings, advanced practice nurses may initiate a physical examination of a patient by examining the components of the HEENT system. Assessing primary diagnoses and differential diagnoses as they concern the HEENT system are important in informing your practice in providing optimal care.

For this Discussion, consider the following three case studies of patients presenting with head, eyes, ears, nose, and throat disorders.

Case Study 3

A middle-aged female presents to the office complaining of strep throat. She states she suddenly developed a sore throat yesterday afternoon, and it has gotten worse since then. During the night she felt like she was chilled and feverish. She denies known recent contact with anyone else who had strep throat, but states she has had strep before and it feels like she has strep now. She takes no medications, but is allergic to penicillin. The physical examination reveals a slender female lying on the examination table. She has a temperature of 101 degrees Fahrenheit, heart rate of 112, respiratory rate of 22, and blood pressure of 96/64. The head, eyes, ears, nose, and throat evaluation is positive for bilateral tonsillar swelling without exudates. Her neck is supple with bilateral, tender, enlarged anterior cervical nodes.

To prepare:

Review the case studies provided in this week’s Resources.
You will either select or be assigned one of the three case studies provided.
Reflect on the provided patient information including history and physical exams.
Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis.
Reflect on potential treatment options based on your diagnosis.
Post an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study you selected. Describe the role of the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.

Discussion: Diagnosing HEENT Disorders

Case Study 1

An 86-year-old widowed female is brought to the office by her daughter-in-law. The patient complains of constant tearing and an itchy, burning sensation in both eyes. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The patient complains that her eyes are dry. She thinks the problem must be caused by one of her medications. Her patient medical history is positive for hypertension, atrial fibrillation, and heart failure. She has an allergy to erythromycin that causes rash and elevated liver enzymes.

Medications currently prescribed include Furosemide 40 milligrams po twice a day, diltiazem 240 milligrams po daily, lisinopril 20 milligrams po daily, and warfarin 3 milligrams po daily. The physical examination reveals a frail older female with some facial dryness and slight scaling. Her visual acuity is 20/60 OU, 20/40 OD, 20/60 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes. Sclera are injected, conjunctiva are pale, and pupils are equal and reactive to light and accommodation.

The patient is 86-year-old and complained of constant tearing, itching, and burning sensation. The patient also reports facial dryness, slight scaling, red, and swollen crusting around the eyelashes. Her complaint is not sudden but has become gradually worse daily now affecting her vision. Primary diagnosis for the patient is dry eye syndrome.  Dry eye syndrome consists of a wide spectrum of disorders with different causes. Symptoms are dry, scratch, gritty feeling in the eyes along with burning or stinging pain, redness, itching, excessive tearing or light sensitivity, aching sensations, heavy eyes, fatigued eyes, and blurred vision (Buttaro et al., 2013).

These symptoms are almost the same with what the patient complained about. Since the patient had this problem before and it is not new, this could be dry eye syndrome. With the burning sensation in both eyes, constant tearing and itchy and dry eyes,  with some a drop or two of artificial eye drop it could solve this problem. A thorough history and investigation is necessary to identify the cause of dry eye. Useful clinical tests for assessing the severity of the condition include Schirmer, fluorescein dye, and tear break up time tests. Management depends on an accurate diagnosis and the severity of the condition (Buttaro et al., 2013).

Treatments that replenish deficient tears include artificial tears, gels and ointments in mild to moderate disease. Other treatment modalities such as topical steroids, immunomodulating drugs, antibiotics, bandage contact lenses, autologous serum and amniotic membrane transplantation may be used in more severe cases. In severely dry eyes, surgical intervention such as punctal occlusion can be employed to minimize tear drainage. Certain conjunctival and lid operations can also be performed to treat specific causes (Tuft & Lakhani, 2008).

Differentials:

Allergic Conjunctivitis: Allergic conjunctivitis happens when your eyes are exposed to something that you’re allergic to, called an allergen. Examples include grass, pollen, trees, medication or ragweed. Most people over age 65 and mostly female experience some symptoms of dry eyes. Certain medication such as anticholinergic drugs, diuretics (Furosemide) and beta blockers are all associated with dry eye disease (Buttaro et al., 2013). Our patient is on furosemide, which could be the cause of her symptoms and mild cases of dry eyes (Buttaro et al., 2013).

Irritation Conjunctivitis: Irritation conjunctivitis is caused by getting something in your eye. This could be a bit of lotion, a chemical splash, or chlorine from a swimming pool. It could also be caused by a contact lens, an eyelash, or even a crumb. This patient stated that it was not a new problem; it could be one of her lotions, perfumes, soap, or anything in the house that she uses every now and then that she could have irritated her (Rhee, 2017).

Bacterial Conjunctivitis: Bacterial conjunctivitis is an infection of the eye’s mucous membrane, the conjunctiva, which extends from the back surface of the eyelids (palpebral and tarsal conjunctiva), into the fornices, and onto the globe (bulbar conjunctiva) until it fuses with the cornea at the limbus. Since these bacteria are usually spread from other infected individuals, poor hygienic habits may increase the risk of infection, Poor contact lens hygiene, contaminated cosmetics, crowded living or social conditions such elementary schools, military barracks etc (Granet et al., 2008). This patient is 86 and might have some dementia or forgetfulness, not remembering old cosmetics that are contaminated or is unable to care for herself due to old age, which leads to poor hygienic habits.

Signs and Symptoms

All the three differentials diagnosis (Allergic, Irritation and Bacterial Conjunctivitis) have similarities in the sign and symptoms which includes: Red eye: Unilateral, bilateral, or sequentially bilateral, discharge: Classically purulent, but may be thin or thick muco-purulent or watery, Irritation, burning, stinging, discomfort, tearing, light sensitivity, intolerance to contact lens, fluctuating or decreased vision. All of them are related to the patient (Jap, 2008).

Discussion: Diagnosing HEENT Disorders

Diagnosis

Conjunctivitis can be diagnosed through a comprehensive eye examination. Testing, with special emphasis on the conjunctiva and surrounding tissues, may include: Patient history to determine the symptoms, when the symptoms began, and whether any general health or environmental conditions are contributing to the problem. Visual acuity measurements to determine whether vision has been affected. Evaluation of the conjunctiva and external eye tissue using bright light and magnification. Evaluation of the inner structures of the eye to ensure that no other tissues are affected by the condition. Supplemental testing, which may include taking cultures or smears of conjunctival tissue. This is particularly important in cases of chronic conjunctivitis or when the condition is not responding to treatment (Granet et al., 2008).

Treatment

The first step is to remove or avoid the irritant, if possible. Cool compresses and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, nonsteroidal anti-inflammatory medications and antihistamines may be prescribed. People with persistent allergic conjunctivitis may also require topical steroid eye drops (Kymionis et al., 2008). Bacterial conjunctivitis. This type of conjunctivitis is usually treated with antibiotic eye drops or ointments. Bacterial conjunctivitis may improve after three or four days of treatment, but patients need to take the entire course of antibiotics to prevent recurrence.

References

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary Care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.

Granet DB, Dorfman M, Stroman D, et al. (2008).  A multicenter comparison of polymyxin B                sulfate/trimethoprim ophthalmic solution and moxifloxacin in the speed of clinical efficacy for                the treatment of bacterial conjunctivitis. J Pediatr Ophthalmol Strabismus 2008;45:340–349.

Latkany R. Dry eyes: etiology and management. Curr Opin Ophthalmol. 2008;19:287–291.

Tuft S, Lakhani S. Medical management of dry eye disease. Dev Ophthalmol. 2008;41:54–74. [PubMed]

Kymionis GD, Bouzoukis DI, Diakonis VF, Siganos C. (2008). Treatment of chronic dry eye: focus on

cyclosporine. Clin Ophthalmol. 2008;2:829–836. [PMC free article] [PubMed]

Jap A, Chee SP. (2008).  Immunosuppressive therapy for ocular diseases. Curr Opin Ophthalmol.               2008;19:535–540. [PubMed]

Rhee, M. K., & Mah, F. S. (2017). Clinical utility of cyclosporine (CsA) ophthalmic emulsion 0.05% for       symptomatic relief in  people with chronic dry eye: a review of the literature. Research &                 Reports in Transdermal Drug Delivery, 91157-1166.doi:10.2147/OPTH.S113437. Retrieved from

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