HEENT, Essay Example

Peggy L. is a 15 year old female who presents with a sore throat for 2 days. In order to properly diagnose her illness, we must first collect subjective data from her by asking her about her symptoms. Important questions to ask her will include “How long have you had a sore throat?”, “Does it hurt all the time? Does it hurt only when you swallow?”, “Are you able to breathe normally?”, “Do your ears hurt?”, “Do you cough? Does it feel dry? Does mucous come up?”, “Do you sneeze more than normal?”, and “Are you less energetic than usual? Do you find yourself sleeping more than usual?” These are important questions to ask, because a sore throat can be a symptom of many different illnesses, most of which are treated very differently (Jarvis, 2007). The main importance of asking these questions is to distinguish whether the patient has strep throat, the flu, the common cold, tonsillitis, or allergies. If the patient feels more tired than usual, has had a sore throat for a few days that hurts persistently, coughs and sneezes, then she likely either has the common cold or the flu. If the sore throat is the only symptom, and has persisted for a few weeks, she likely has tonsillitis. If she is sneezing with mucous coming up, it is likely an allergy problem.

Objective data that should be collected include health information relating to the patients’ prior sore throats and colds in addition to documentation on her allergies. If the patient has had sore throats frequently throughout her lifetime, then she likely has tonsillitis. If the patient has colds frequently, then she might have some sort of immune problem or exposure that increases her risk of getting a cold, and this is most likely what is making her sick. If the patient has a record of allergies that cause sore throats, then this is likely the problem (Seller, 2000).

It is important to order several diagnostic tests to determine which illness the patient has. A throat swab should be used to test for strep throat; if streptococcal bacterial colonies grow on the plate, then she has this illness (Bickley, 2005). To test for tonsillitis, she should be given a physical exam of the throat to see if the tonsils are inflamed (Swartz, 2010). A basic physical exam to confirm the symptoms that the patient reports can be used to diagnose both the common cold and the flu.

Questions and Answers:

Which illnesses cause a sore throat and are bacterial in nature?

Strep throat and tonsillitis.

How do you treat tonsillitis?

While doctors used to remove the tonsils, they now prefer to prescribe an antibiotic regimen and tell the patient to rest, drink fluids, and eat smooth fluids during recovery.

References

Bickley, L (2005). Bates Guide to Physical Exam and History Taking. (9th edition). Lippincott

Jarvis, C. (2007). Physical examination and health assessment. (5th edition). Saunders: St. Louis

Seller, R. (2000). Differential Diagnosis of Common Complaints, Philadelphia, W.B. Saunders

Swartz, M.A. (2010). Textbook of Physical Diagnosis: History and Examination (6th ed.). W.B. Saunders.