HEENT Case Study 2

Alexander Warren
NURS 6211
Case Study II
1. Do you need any additional subjective data from this patient?

We are told that the patient has been treated in the past for sinusitis but how many times and how
long has it been since she was seen for this problem? Sinusitis can be caused by allergies, does
this recurrent sinusitis happen at certain times of the year? Does she have other conditions that
may result in poor sinus drainage such as GERD, cystic fibrosis, or immune system diseases? Is
she having reoccurring respiratory tract infections that having slowed her mucus drainage? Has
she ever had any facial surgery or trauma in the past? Does she live in a highly polluted area or
use strong perfumes that could be causing nasal inflammation? Does she do a lot of swimming
in chlorinated pools? How long has she been using the OTC nasal decongestants, using them for
prolonged periods of time can cause rebound nasal congestion. Does she smoke, as this can
cause inflamed sinuses.
2. What additional objective data might you need and for what reason?
Does the patient have a deviated septum? This can cause a decrease in mucus drainage. Does
the patient have nasal polyps? This can also block the sinuses. Is there any obvious trauma to
the face? How is the patients dentition as poor dentition can cause chronic infections. How do
the patients lungs sound? Does she have asthma? Asthma and chronic sinusitis are common
together. Is there any clicking or popping in the patients jaw? Could TMJ be a factor in the
patients symptoms?
3. What lab tests might you order and why?
There are quite a few tests that can be ordered to help diagnose a cause of sinusitis. Since the
patient has had more than one episode of sinusitis, cultures may be necessary to ensure the
proper antibiotic is prescribed. A nasal endoscopy may be performed to better visualize the
sinuses and check for physical deformities such as polyps that can cause sinusitis. An allergy
study would be beneficial due to seasonal allergies causing sinusitis. Allergy shots or
medications could prevent further cases of sinusitis. Also, imaging studies may be performed
such as an MRI or CT. Since cancer of the sinuses is rare this would be one of the last studies
ordered.
4. Review the anatomy and physiology (A&P) of the head and neck. Create a list of working
differential diagnoses.
Chronic/acute sinusitis, fungal sinusitis, viral sinusitis, allergic/nonallergic rhinitis, tumors of the
sinuses/nasal cavities, GERD, nasal polyps causing chronic sinusitis, cystic fibrosis, turbinate
dysfunction, TMJ
5. Which ones will you rule out and WHY? 6. What microorganisms are most common in acute
cases of sinusitis? What bacteria are you more likely to see in chronic sinusitis?
The first to be ruled out would be fungal sinusitis. It is uncommon and come with other
symptoms such as mental status changes and dark ulcers in the nasal canal and the roof of the
patients mouth. It is impossible to rule out everything without the results of needed tests.
Tumors of the sinuses/nasal cavities would be ruled out by imaging studies. Nasal polyps would
be ruled out through endoscopy. GERD, would usually present with other symptoms such as
heartburn and the feeling of reflux in the throat. TMJ would be ruled out by pressing on the joint
while the patient moves their jaw, also imaging studies may be done. Cystic fibrosis will usually
have other symptoms that include breathlessness, thick sputum with coughing, exertional
dyspnea, constipation, and recurrent lung infections. If needed a sweat test or genetic testing
could be done to rule out cystic fibrosis.
Acute cases of sinusitis are usually associated with viral infections but the most common type of
bacteria found when an aspirate is performed is S. pneumonia (Wald, 2011).
Usually bacteria are considered a secondary invader when discussing chronic sinusitis. The most
common found bacteria in chronic sinusitis is Staphylococcus aureus (Ramadan, 2012).
7. What are the medical and nursing diagnoses?
It is impossible to make an accurate diagnosis with the limited information given. With what the
case study provides, I will say Unspecified Chronic Sinusitis, icd code 473.9. This chronic
sinusitis could be caused by any number of factors and until the cause is found it is impossible to
treat the condition properly.
There are several nursing diagnoses that could apply. Acute/Chronic pain: sinuses/head,
ineffective airway clearance due to thickened secretions/obstructed nasal passages and anxiety
related to recurring disease (www.nanda.org, 2014).
8. What is your plan of care? Will you order antibiotics? Why or why not?
My plan of care would begin with attempting to find the factor that is causing the chronic
sinusitis. Is it allergies, obstruction, or other disease processes. My initial treatment would be
determined by how she was treated for this same problem in my office in the past. Was she
given antibiotics? Was it effective in the past and how long has it been since she had these
symptoms? If she was given antibiotics in the past and it was quite some time ago I would treat
her the same and order further testing like allergy testing or an endoscopy depending on how
severe/frequent this occurs. If she was seen two weeks ago and was given antibiotics but the
problem persisted or has come back quickly, I would consider changing the antibiotic or
extending the course. It probably is not due to viral causes when the duration of symptoms have
lasted for 3 weeks this leads me to believe that it is more than likely bacterial in nature. I would
probably start the patient on Augmentin 250 mg three times a day for 4 weeks, nasal saline
irrigations 2-3 times a day, and Flonase 2 sprays each nostril daily. I would also give the patient
codeine/guaifenesin 10/100 per 5ml to take 10ml before bedtime to help with nighttime cough. If
anything serious was shown on the imaging studies or endoscopy I would change treatment in
accordance to the findings. I would also start the patient on an allergy medicine like Claritin 10
mg daily to help prevent nasal swelling due to allergies and hopefully prevent this problem in the
future. The need for antibiotics is questionable but with a duration of 3 weeks and the
reoccurrence of these symptoms I think it is reasonable.
9. What follow-up does this patient need? What health education will you provide?
Follow up would be determined by what type of testing was ordered. If the sinusitis occurred
frequently and I ordered an endoscopy, allergy testing, or imaging studies I would have the
patient follow up status post testing to discuss results and how we would proceed in treatment of
the issues. If this was only her second time having these symptoms and I did not order testing I
would have the patient follow up if symptoms did not resolve or if they reoccurred after
treatment. I would inform the patient of the risks/benefits of all tests that I ordered and why they
were needed. I would teach the patient about the disease process and how the swelling of the
nasal passages blocks drainage and makes a perfect environment for bacterial growth. Smoking
cessation would be important as this is an irritant and can cause inflammation of the
passageways.
10. What additional patient teaching may be needed?
Push fluids to keep mucous thin, use OTC pain relief medications for headaches or sinus pain,
inhale steam to open nasal passages and thin mucous, elevate head while sleeping to promote
drainage, do not use antihistamines as these may thicken mucous, call provider if fever gets
above 101.5 or if OTC medications do not help with headache.
11. Do you incorporate complementary therapies in your plan of care? Specifically what might
these be?
Support with evidence from the scientific (data-based) literature.
There is some evidence that herbal therapies such as stinging nettle and Bu Qi Gu Biao not only
relieve the symptoms of sinusitis but the patients suffer a shorter course of the disease (Sayin,
2013). My level of knowledge dealing with herbal remedies is very limited and I would not feel
comfortable suggesting any to patients without further education. Saline irrigation would
defiantly be a recommendation due to the affect it has at clearing nasal passages, removing
infectious drainage, and easing inflammation (Adappa, 2012).
12. What billing code is appropriate? What is the E&M level?

Taking what is contained in the case study as a guide I would choose a 99213. The patient is
already established and I meet the criteria for 99213 by meeting the requirements for Expanded
Problem Focused History and Low Complexity Decision Making with my plan of care. It would
be difficult to advance to 99214 with there being almost no physical exam noted in the case
study. As stated above I would use a diagnosis code of 473.9 (chronic unspecified sinusitis) due
to this being a recurring problem of unknown etiology.
13. What Healthy People 2020 objective warrants consideration and/or general public health
concerns?
EH-1 or EH-3 could be beneficial to this patient. The chronic sinusitis may be caused by allergic
factors such as pollution and improving air quality and reducing airborne toxins may help
decrease the number of cases with these symptoms (healthypeople.gov, 2014)
OH-3.2 may be important if the patient has poor dentition which is causing the chronic sinus
infections (healthypeople.gov, 2014) .
RD-7.1 could be used if the patient was also diagnosed with asthma as this can be a contributing
factor for chronic sinusitis (healthypeople.gov, 2014).
TU-1 is very important to this patient as it attempts to reduce the use of cigarettes in adults. It
states that 20.6% of adults were smokers in 2008 and hopes to reduce that to 12%. Cigarette
smoking can lead to chronic cases of sinusitis.
14. How might this patient be helped with a Circle of Caring?(See Dunphy-Winland book)
The cornerstone of the Circle of Caring, is of course, caring. Not only treating the disease
process but treating the patient as a whole through advocacy, patience, and being authentic in
your interactions with the patient. All too often providers only see a number instead of a person
sitting on the exam table. We have to remember that we were nurses first and a holistic approach
should be taken when treating patients. The Circle of Caring is a nursing-based template superimposed on the traditional medical model to create a new whole (Dunphy-Winland, 2011).
While taking subjective findings with this patient, and all patients, we should remember to
genuinely listen to their complaints and not tune them out when we have the problem solved.
The amount of information gained through listening to everything the patient says gives a much
larger base to correctly diagnose. We must be patient and not simply give throw antibiotics at
problems like this to move them along. Being committed to treating the patients as a whole is
beyond important. This case could easily be something more serious than simply a sinus
infection and writing a prescription for that and sending them out the door could be detrimental.
We have to remember that a patient centered approach is how we were taught and should be the
basis for our treatment model.
2020 Topics & Objectives Objectives A-Z. (2014, September). Retrieved September 29, 2014,
from http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
Adappa, Nithin D., Calvin C. Wei, and James N. Palmer. "Nasal Irrigation with or without
Drugs." Current Opinion in Otolaryngology & Head and Neck Surgery 20.1 (2012): 53-57. Web.
29 Sept. 2014.
Definitions and Classifications Errata Notes. (2014). Retrieved September 29, 2014, from
http://www.nanda.org/nanda-international-d-c-book-errata-notes.html
Dunphy, L. M., & Winland-Brown, J. E. (2011). Primary care: The art and science of advanced
practice nursing. Philadelphia, MS: Davis company.
Ramadan, Hassan H. "Chronic Rhinosinusitis in Children." International Journal of Pediatrics
2012 (2012): 1-5. Web. 29 Sept. 2014.
Sayin, Ibrahim, Cemal Cingi, Fatih Oghan, Bahadir Baykal, and Seckin Ulusoy.
"Complementary Therapies in Allergic Rhinitis." ISRN Allergy 2013 (2013): 1-9. Web. 29 Sept.
2014. <http://www.hindawi.com/journals/isrn/2013/938751/>.
Wald, E. R. (2011). Acute Otitis Media and Acute Bacterial Sinusitis. Clinical Infectious
Diseases, 52(Supplement 4), S277-S283. doi: 10.1093/cid/cir042

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Alexander Warren

1. Do you need any additional subjective data from this patient?

12. What billing code is appropriate? What is the E&M level?

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