Subjective
The patient’s chief complains a decreasing appetite, headaches, and pain while swallowing, which goes gradually to the development of running nose with a slight hoarseness in her voice as much as her sound is not congested. When a patient has hoarseness, there is a disturbance on the normal vibrational of the vote, which is likely to result from a manifesting illness, especially laryngeal disease. Naturally, the voice is produced by vocal folds and appropriately taken through airflows between cords and, thus, the vibration effect. The larynx is a musculocartilaginous organ between a mucous membrane connecting superiorly to the pharynx and inferiorly to the trachea. Conditions such as hoarseness come from infections of respiratory diseases, acute laryngitis, and components such as restrain in crying or anger expression.
For the history of the present illness, we notice that the patient is 20-years-old female CC who decided to take her condition seriously 3 days ago after realizing that there was an outbreak flu-like symptoms that swept the campus community about two weeks ago. The characteristic of the disease includes loss of appetite, headaches, and pain while swallowing. From such a description, the infection’s timing is likely to be around two weeks ago when there was an outbreak of the flu. In such a case, the relieving factor is that the patient’s voice is not congested as much as it includes soreness in the throat. From a doctor’s perspective, I can approximate the pain to be around seven on a scale of 1-10.
Some of the diseases that the patient is likely to be suffering from maybe; allergies and asthma, onset, trauma history, and exposure. Acute onset of hoarseness is a possibility since it usually results from an infection or trauma, which comes either as a direct injury or from screaming. Such overuse can gradually hence result in progressive hoarseness and vocal cord changes. In addition to such a possibility, is a congenital problem is from birth, such as laryngeal web, angioma, or palsy. The newborns with such complications as aphonia or hoarse cry cannot be quickly resolved to have a congenital anomaly, vocal cord paralysis, or papilloma.
Exposure is another possibility because there was a viral infection within a region where the patient was and in our patient’s case, is the university flu infection. Such viruses can easily be spread through droplets secretion direct from an infected individual. The outbreak came right from a group of classmates, and later after two weeks, it is seen sweeping students in the local community college. The clinic results that treated Lily indicate that there they have seen the same symptoms from students from the same learning institutions as Lily’s. Nasal trauma or fracture history is also another possibility of the complication, which is rare but post-traumatic severe cerebrospinal fluid rhinorrhea presence.
Lily could be having some allergic reaction towards a particular agent, mostly exposed to the university. In this case, allergies can be chronic, for it keeps recurring with an irritation sensation and swelling on both the lower and upper airways. People suffering from such an allergic reaction are likely to be having a disorder, which in most cases, is asthma. The individual thus develops vocal cord edema, hoarseness, or inflammation. The above possibilities are likely to be the first diseases that healthcare workers are likely to check first before undergoing further medical checkups. Moreover, it becomes more comfortable now that the patient has had a history from the college’s flu-outbreak.
Having known the above, the doctor can acquire some other diagnostic clues that can heal Lily. Such is possible by only asking her if there are changes in the hoarseness during the day if she feels pain, other symptoms that can be involved, and neurological disorder. The doctor is in a position where he can detect where there are changes during the day, and if there are, it suggests that the infection is most likely mobile. Such a condition, in most cases, shows that the patient will be having a familiar voice in the morning, but it progresses to hoarseness during the day.
The presence of pain is always associated with an inflammatory process such as URI or GERD. The problem happens later in laryngeal cancer; on the other hand, the neurologic and hormonal causes are not as painful. If the patient or Lily, in our case, has some associated symptoms such as cough, shortness of breath, ear pain, loss of weight, or throat pains, should, in most cases, raise concern mostly about neoplasm, systemic diseases, or neurologic causes. Hormonal disorders may cause severity on the degree and the duration of the illness. Having a history of other conditions such as parkinsonism, amyotrophic, myasthenia can have progressive dysarthria and dysphagia. And lastly, having a gastroesophageal reflux disease can easily cause inflammation of the posterior larynx and mostly arytenoid mucosa. If the patients also report a constant habit of throat clearing with a sensation, caution needs to be done, for it is likely to damage the vocal folds.
Current Medications focusing on physical examination
After listening to the quality of the patient’s voice, which includes the range at which the agent can reach, loudness, pitch, and efforts at which an individual is required to put into creating the voice. The diagnostics that evaluates the voice can suggest the type of medication to administer to the patient. When the range is monotonal to its extreme variables, the patient is likely to have Parkinson’s disease or depression. The loudness of the voice can either be loud or soft, showing that the patient is suffering from environmental, systemic disease, or psychological. The agent can be high, low, glottal, and raspy, suggesting that an individual could be at the puberty stage with a soft voice, mostly on males. The register is the presence of any agent, which can be vocal fatigue and an overdose. Quality through measuring where the patient is breathy to resonant could be vocal cord mass, paresis, atrophy, and bowing.
From the analysis above, we are likely to get some of the medication that can enable the patient to feel better. Lily, as we have seen early, could most likely be having Polyps condition showing that Lily is most likely having an allergic reaction, or maybe she was engaged in a scenario where she was forced to a lot of her voice, GERD, which has a progressive’s hoarseness which changes in the morning and progresses throughout the day. Polyps visible on vocal cords thus need an over the counter medication (OTC) such as an ENT referral for a biopsy that lasts for at least two weeks. However, before coming to such a conclusion, the doctor needs to consider some of the patient’s allergic reactions accompanying the medication. These allergic reactions could come from environmental food factors and some specific medicines.
Objective
For such a diagnosis, some physical symptoms that the caregiver is likely to get is a faint voice or a completely lost voice, dry throat, sore throat, dry and irritating cough, and a constant urge to clear the throat. For Lily’s case, we can easily conclude that her infection is likely to associate with other illnesses such as the outbreak of flu in the university. Some of the symptoms that need close observation are headaches, ache, and pain, pain, especially while swallowing, and fever. The patient mostly decides on seeing the doctor, especially is they have difficulties in breathing and high-pitched wheezing and drooling. The doctor will do a close examination of redness around the throat and blood infection and a throat swab test for any possible condition on the upper airways.
Assessment
Voice is one aspect that the caregivers assess the most thorough fundamental value through computer programs. Such an assessment aims to quantify pharyngeal exposing gastric contents in patients by diagnosing them with reflux-relating hoarseness and healthy controls by using new diagnostic techniques. Some of the critical aspects of assessing, in this case, come in two distinct groups which are, non-instrumental which do not need any equipment to examine the disorder where else the instrumental methods are, on the other hand, an objective that is looking the conditions and include proper observation through radiography and electromyography.
Plan
Like any other health worker, the objective, in this case, is to ensure that Lily gets back to her good health with proper medication. The end goal is acquiring the best medicine by analyzing all the possible factors that could be causing the complication. After studying Lily’s colleagues, it will only be fair if Lily undergoes the same laboratory procedures and tests to show the difficulties.