NURS 6541: Primary Care of Adolescents and Children | Week 4

Patients with disorders of the eye, ear, nose, and throat (EENT) often present with a variety of symptoms that can be associated with multiple disorders. This makes diagnosis difficult because what may appear to be a gastrointestinal or respiratory disorder, for example, might actually be an EENT disorder such as otitis media. Consider 8-month-old Melissa, who presents with a complaint of tugging on her left ear, fussiness, and decreased appetite over the last 3 days. She does not have a fever, and her physical examination is normal. As the advanced practice nurse caring for patients like Melissa, you must always consider the differential diagnoses and perform the appropriate assessments and diagnostics prior to providing treatment and management recommendations for patients and their families.

This week you explore eye, ear, nose, and throat disorders in pediatric patients. You also examine differential diagnoses for these disorders, as well as the impact of patient culture on treatment, management, and education.

Learning Objectives – Discussion: Evaluation & Management of HEENT Disorders

By the end of this week, students will:

• Assess pediatric patients for eye, ear, nose, and throat disorders
• Evaluate differential diagnoses for pediatric eye, ear, nose, and throat disorders
• Analyze treatment and management plans for pediatric patients with eye, ear, nose, and throat disorders
• Analyze strategies for educating parents on their children’s disorders
• Evaluate the impact of culture on the treatment and management of eye, ear, nose, and throat disorders
• Understand and apply key terms, principles, and concepts related to eye, ear, nose, and throat disorders in pediatric patients
• Assess pediatric patients with signs of eye, ear, nose, and throat disorders

Learning Resources

Required Readings

• Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L.  (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.
• • Chapter 29, “Eye Disorders” (pp. 703-735)This chapter reviews the development, physiology, and pathophysiology of the eye. It provides guidelines for eye care including assessment and management strategies for common eye disorders, injured eyes, and deformities of the eyelids.

• Chapter 30, “Ear Disorders” (pp. 736-755)This chapter reviews the structure and function of the ear and presents guidelines for the assessment and management of ear problems.

American Academy of Pediatrics. (2004). Clinical practice guideline: Diagnosis and management of acute otitis media. Pediatrics, 113(5), 1451–1465.

This article examines the diagnosis and management of uncomplicated acute otitis media in patients from 2 months to 12 years of age. It focuses on defining acute otitis media, pain management, assessment, and selection of appropriate antibacterial treatments.

Chow , A.W., Benninger, M.S., Brook, I., Brozek, J.L., Goldstein, E.J.C., Hicks, L.A., Pankey, G.A., Seleznick, M., Volturo, G., Wald, E.R., & File Jr, T.M. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases , 54(8), 72-112.

Note: Retrieved from the Walden Library databases.

Shulman, S.T, Bisno, A.L., Clegg, H.W., Gerber, M.A., Kaplan, E.L., Lee ,G., Martin, J.M., & Van Beneden, C. (2012). Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 58(10), 86-102.

Discussion: Evaluation & Management of HEENT Disorders

In clinical settings, head, eye, ear, nose, and throat (HEENT) disorders account for the majority of pediatric visits. With the prevalence of these disorders, you must be familiar with their signs and symptoms as well as evidence-based practices for assessment and treatment. Although many pediatric patients present with common HEENT disorders such as ear infections, allergies, and strep throat, some patients present with rare disorders requiring specialist care. In your role, making this distinction between when to treat and when to refer is essential. For this Discussion, examine the following case studies and consider potential diagnoses and management strategies.

Discussion board posting assignments are assigned alphabetically by FIRST NAME to ensure all cases are covered and discussed.

• Case Study 1: A-F
• Case Study 2: G-M
• Case Study 3 N-Z

Case Study 1:

HPI: A mother presents with her 2-year-old African American male child with complaints of ear pain and decreased sleep. Earlier this week, he had a runny nose and congestion with a mild cough that occurred mostly when lying down. His temperature is 100.7.

PE: Pt is walking around room, exploring in no acute distress.
HEENT: Mild nasal congestion, clear postnasal drainage, and lungs clear to auscultation. Ear exam reveals right tympanic membrane erythematous, translucent, in a neutral position, with no pus or fluid noted. Left tympanic membrane is full, reddish/orange in appearance, and opaque with pus.
Neck: Shotty anterior cervical adenopathy
Lungs: Clear to auscultation

Case Study 2

HPI: Kevin is a 5-year-old Asian American boy with an intermittent 2-day history of nasal congestion and cough in the early morning. His mother reports thick, green nasal discharge. He is afebrile, and appetite and sleep are normal.

PE: A smiling male patient sitting on mom’s lap.
HEENT: Tympanic membranes pearly gray without fluid in a neutral position, no cervical adenopathy, nasal turbinates are red, and clear rhinorrhea and postnasal drip.
CV: RRR, no murmurs or gallop
PULM: clear to auscultation

Case Study 3

HPI: Marcus is an 8-year-old with a 36-hour complaint of headache (frontal), sore throat, fever to 102°F, and nausea. Mom says his appetite is decreased and his breath smells “like a puppy dog’s.”

PMH: A Polish 8-year-old boy, in mild distress.
HEENT: Tympanic membranes partially obscured by cerumen but in neutral position and transparent, 2+ enlarged and red tonsils with exudate, strawberry tongue, and petechiae on the soft palate enlarged tonsillar and anterior cervical lymph nodes.
CV: RRR
PULM: Clear to auscultation bilaterally

To prepare for Discussion: Evaluation & Management of HEENT Disorders:

• Review “Eye Disorders” and “Ear Disorders” in the Burns et al. text.
• Review the three case studies focusing on the case that is assigned to you. Analyze the patient information, including the parent’s perspective.
• Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
• Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
• Consider strategies for educating parents on the child’s disorder and reducing any concerns/fears presented in the case study.

By Day 3

Post an analysis of your assigned case by responding to the following:

• • What additional questions will you ask?
    • Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds and so forth, that might be pertinent in arriving to your differential diagnoses).
  • What additional examinations or diagnostic tests, if any will you conduct?
  • What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.
  • What is your most likely diagnosis and why?
  • How will you treat this child?
    • Provide medication treatment and symptomatic care.
    • Provide correct medication dosage. Use the knowledge you learned from this week’s and previous weeks’ readings as well as what you have learned from pharmacology to help you with this area.
  • Patient Education, Health Promotion & Anticipatory guidance:
    • Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
    • Include any socio-cultural barriers that might impact the treatment and management plans.
    • Health Promotion:
      • What immunizations should this child have had?
      • Based on the child’s age, when is the next well visit?
      • At the next well visit, what are the next set of immunizations?
      • What additional anticipatory guidance should be provided today?

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in both of the ways listed below. Respond to a colleague who chose one of the first three case studies and a second colleague who chose one of the last three case studies. Choose colleagues who selected a different case study than you did.

• Explain how culture might impact the diagnosis, management, and follow-up care of patients with the respiratory, cardiovascular, and/or genetic disorders your colleagues discussed.
• Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or different perspectives.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Discussion: Evaluation & Management of HEENT Disorders

ADDITIONAL INFORMATION;

Evaluation & management of HEENT disorders

Introduction

The HEENT is the craniofacial region, consisting of the jaws, cheeks, nose, mouth and related structures. It also includes eyelids, which are considered to be part of the Ophthalmological System (OS). The HEENT can be affected by numerous disorders that affect a patient’s vision or hearing.

Patient History

• Ask the patient to describe their symptoms:

• What are your eye symptoms?

• Have you had any surgeries or procedures for this condition? Why were they performed, and what was the outcome of those procedures?

• Describe any past medical history that may affect their current condition (i.e., allergies, heart disease) and how these conditions have been treated in the past.

• Ask about any family history of HEENT disorders; if so, ask them to share details about that family member’s experience with an HEENT disorder or other disease process such as diabetes mellitus type 2 (DM2).

Examination

The HEENT examination is a vital part of the evaluation and management of patients with head and neck disorders. The primary purpose of this examination is to identify any signs or symptoms that may suggest an underlying cause for your patient’s problem. This can include:

• Signs or symptoms related to infection, trauma, malignancy, inflammation or vascular disease (e.g., temporal artery mass).

• Signs or symptoms related to neurologic disease (e.g., seizure disorder).

Diagnostic Testing

Diagnostic Testing

Laboratory tests, imaging studies, and other tests may be used to evaluate your condition. You may also be asked to provide a saliva sample (called a “saliva specimen”) that is tested for specific antibodies or proteins that are associated with inflammatory diseases of the eye.

Treatment

Treatment depends on the cause of your condition. Common treatments include surgery or medications to relieve symptoms and improve your quality of life.

If you are having trouble swallowing, you should see your doctor right away. If you have a persistent cough, persistent hoarseness or chronic cough (more than 3 months), it may be caused by something other than an infection like cancer or pneumonia. In this case, treatment for these symptoms will not help much except for temporary relief until they resolve on their own over time.

Discussion

The management of HEENT disorders is usually based on a systematic approach. The main goals are to prevent future complications and reduce their severity, which can be achieved by early identification of potential problems.

The main treatment is conservative medical treatment such as antibiotics when needed. If there are no signs of inflammation or bacterial infection (elevated temperature), surgery may not be necessary in most cases; however, if your child has severe blepharospasm or strabismus (squint), you should consider surgical intervention to ensure that their eyes remain symmetrical after healing has occurred.

In addition to conservative management plans for the patient themselves, parents should also discuss these plans with their child’s physician so that they understand what steps will be taken if there are any complications during recovery time following surgery/treatment sessions scheduled at home .

Evaluation & management of HEENT disorders

• History/Physical Exam

The patient’s history should include information about their symptoms and the treatment they have received. The examination should be conducted in a quiet, private room with minimal distractions. Patients may have difficulty remembering details about their symptoms or the treatments they’ve received if there is too much stimulation around them. If you feel it is necessary for comfort, you can ask your patient if they would like to take a break from the interview before continuing with any testing procedures (such as an eye exam).

• Diagnostic Testing

When evaluating patients with HEENT disorders such as glaucoma, cataracts and blepharitis (lids), there are several tests that can be performed depending on the condition under investigation: dilated fundoscopy (Duff test); slit lamp biomicroscopy; tonometry measurements; intraocular pressure measurement; slit lamp biomicroscopic examination; anterior segment ocular embryology study (OECS); retinal photography including macular thickness measurement

Conclusion

The HEENT is a complex system, and any pathology in any one of the components can have a significant impact on patient health. The diagnostic assessment of patients with facial pain or headache should include careful history taking and thorough examination before ordering diagnostic tests.