NUR 2180 Documentation of Problem Based on Patient Complaints Essay

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NUR 2180 Documentation of Problem Based on Patient Complaints Essay

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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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