B.W. is a 44-year-old man who presents to the family practice with complaints of sore throat, hoarseness, and a dry cough that worsens at night. He states that the cough started 6 days ago, and the sore throat and hoarseness began 3 days ago and appear to be getting worse The patient has a history of prediabetes, which is controlled through diet and exercise. Vital signs are T 99.5, P 58, R 16, and BP 110/55.
Question 1
What subjective information should the nurse obtain?
Question 2
The nurse is assessing the structures of the oral cavity. What are the physical features?
Question 3
The nurse notes that the patient’s teeth are stained yellow and asks the patient about tobacco use. The patient states that he chews one bag of tobacco every other day. What health promotion concepts should the nurse include in the teaching plan?
Question 4
What is the most likely cause of this patient’s cough, sore throat, and hoarseness?
Full Answer Section
Question 2: Physical Features of the Oral Cavity
The nurse should assess the following physical features of the oral cavity:
- Color: The oral mucosa should be pink and moist.
- Ulcers or lesions: Check for any sores, ulcers, or abnormal growths.
- Tonsils: Assess the size and appearance of the tonsils, noting any redness or swelling.
- Posterior pharyngeal wall: Examine the back of the throat for redness or exudate.
Question 3: Health Promotion Concepts
The nurse should include the following health promotion concepts in the teaching plan:
- Tobacco Cessation: Advise the patient about the harmful effects of tobacco use and encourage him to quit. Provide information about resources available to help him quit, such as nicotine replacement therapy or counseling.
- Oral Hygiene: Emphasize the importance of good oral hygiene, including brushing twice daily, flossing, and using a mouthwash.
- Regular Check-ups: Encourage the patient to see a dentist for regular check-ups and cleanings.
- Healthy Lifestyle: Advise the patient to maintain a healthy lifestyle, including a balanced diet, regular exercise, and adequate sleep.
Question 4: Most Likely Cause
Based on the patient's symptoms, the most likely cause of his cough, sore throat, and hoarseness is acute viral pharyngitis. This is a common viral infection that often resolves on its own within a week or two. However, if the symptoms persist or worsen, it is important to rule out other potential causes, such as bacterial infections or gastroesophageal reflux disease (GERD).