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. 45 year old male presents to the clinic with a right sided sore throat for the past 3 days which radiates to the right ear. Upon arrival, he was experiencing spasms in his jaw muscles and was unable to open his mouth fully. His past medical history is significant for recurrent peritonsillar abscesses (x5), a childhood history of having mumps and sexually transmitted infections ( N. gonorrhea and C. trachomatis ). He is a current smoker and is sexually active with male partners. Review of systems shows a ***/10 sharp, right sided throat pain, difficulty swallowing, ear pain and shortness of breath. He denies fever, chills, rhinorrhea. His vitals are
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Introduction: The following answer provides an approach to evaluating the patient with a sore throat and jaw muscle spasms. It includes documentation of subjective and objective findings, identifying actual or potential risks.
Answer: Based on the provided history, the 45-year-old male patient presents with a sore throat for the past three days on the right side, which radiates to the right ear. The patient is experiencing spasms in his jaw muscles and is unable to open his mouth fully. The patient’s past medical history is significant for recurrent peritonsillar abscesses (x5), a childhood history of mumps, and sexually transmitted infections (N. gonorrhea and C. trachomatis). The patient is a current smoker and is sexually active with male partners.
A review of the systems shows a ***10 sharp, right-sided throat pain, which is associated with difficulty swallowing, ear pain, and shortness of breath. The patient denies experiencing fever, chills, or rhinorrhea. A thorough evaluation of the neck, nose, mouth, and throat is recommended.
Objective findings may include the examination of the oral cavity, including tonsils and uvula. The assessment of neck lymph nodes, palpation for swelling or tenderness, and listening to the patient’s breath sounds are also important. It is essential to check for neck stiffness, which may be due to meningitis.
Identifying actual or potential risks in this patient is also important. The patient’s history of recurrent peritonsillar abscesses and STIs may point towards an immunocompromised state. The patient’s smoking status puts him at risk of developing respiratory infections, asthma, and lung cancer.
In conclusion, the evaluation of the patient with a sore throat and jaw muscle spasms involves conducting a thorough assessment of the nose, mouth, throat, and neck. It is essential to document the subjective and objective findings and identify actual or potential risks. A comprehensive evaluation of the patient, including a thorough history, physical examination, and possible testing, will help determine an accurate diagnosis and appropriate management plan.
