NURS 6540: Advanced Health Assessment

Assessment 2: HEENT Clinical Case Study Analysis

Master of Science in Nursing (MSN) | Graduate Level

1. Course Context and Assignment Purpose

NURS 6540: Advanced Health Assessment is a core graduate-level course in the MSN program designed to build on foundational physical examination skills and develop advanced clinical reasoning in the nurse practitioner role. Assessment 2 focuses on the head, eyes, ears, nose, and throat (HEENT) system — a clinically dense domain that requires integration of anatomy, pathophysiology, differential diagnosis, and evidence-based practice.

This case study analysis tasks you with applying advanced assessment knowledge to a realistic clinical scenario. You will demonstrate your ability to interpret clinical findings, formulate differential diagnoses, and articulate a structured management rationale grounded in current evidence. This assessment directly maps to the NONPF Core Nurse Practitioner Competencies in assessment, diagnosis, and clinical decision-making.

2. Clinical Case Scenario

CLINICAL VIGNETTE

Mr. David Okafor is a 58-year-old male of West African descent who presents to the nurse practitioner-led primary care clinic with a chief complaint of a “dull, deep ache” in his left eye that has been progressively worsening over the past 36 hours. He rates the pain as 7/10. He reports associated nausea and one episode of vomiting earlier in the day. He denies any purulent or watery ocular discharge. He notes that lights seem unusually bright and uncomfortable. Past medical history is significant for poorly controlled type 2 diabetes mellitus (HbA1c 9.1% at last visit, six months ago), hypertension, and a 15-year history of cigarette smoking (10 pack-years). Current medications include metformin 1000 mg twice daily, amlodipine 5 mg daily, and aspirin 81 mg daily. He has no known drug allergies. Family history includes glaucoma in his father.

On physical examination, the following HEENT findings are documented:

3. Assessment Task Description

Using the clinical case scenario above, you are required to write a 1,500- to 2,000-word analytical case study paper that addresses all four parts outlined below. Your analysis must reflect graduate-level clinical reasoning, demonstrate integration of advanced assessment theory, and be supported by current peer-reviewed evidence published within the last five years.

Part A: HEENT Assessment Interpretation (approximately 400 words)

Critically interpret the documented HEENT findings for Mr. Okafor. For each significant abnormal finding, explain its clinical significance and pathophysiological basis. Identify which findings are most urgent and justify your prioritization. Address the following:

• The significance of the left ocular findings in the context of the patient’s history and risk factors.
• The clinical implications of the fundoscopic findings in both eyes, with specific reference to the associated systemic condition.
• The relevance of the oral mucosal lesions in the context of his medical background.
• A brief interpretation of the ear assessment results and what they indicate.

Part B: Differential Diagnoses (approximately 350 words)

Formulate three differential diagnoses for the primary presenting complaint (left eye pain with the documented findings). For each differential:

1. State the diagnosis and assign a priority ranking (most likely, second, third).
2. Provide a concise clinical rationale based on the case findings.
3. Identify at least two supporting and one refuting feature from the clinical data.

Your differentials must be specific, clinically appropriate to the MSN/NP scope of practice, and referenced with current evidence.

Part C: Diagnostic Reasoning and Further Workup (approximately 350 words)

Based on your primary differential diagnosis, outline and justify the additional diagnostic investigations you would order. Address the following:

• Identify and justify at least three specific investigations (e.g., intraocular pressure measurement, visual field testing, laboratory tests, imaging).
• Explain how each investigation supports or rules out your differential diagnoses.
• Consider the patient’s comorbidities and how they affect your investigative approach.

Part D: Interprofessional Referral and Clinical Decision-Making (approximately 400 words)

Demonstrate advanced clinical decision-making in the context of this case by addressing the following:

• Determine whether an urgent referral or emergency transfer is indicated, providing a clear evidence-based rationale for your decision.
• Identify the specialist(s) to whom you would refer, explaining the urgency and the information you would communicate using a structured handover format (e.g., SBAR or ISOBAR).
• Discuss one additional HEENT finding identified in the case (outside of the eye) and outline how you would manage or follow up on this finding within the NP scope of practice.
• Reflect briefly on how Mr. Okafor’s sociodemographic factors and chronic disease burden should influence culturally responsive, person-centred care planning.

4. Submission Requirements and Formatting Guidelines

All submissions must adhere to the following requirements. Non-compliance may result in mark deductions prior to academic assessment.

• Word count: 1,500–2,000 words (body text only; title page, abstract, references, and appendices are excluded from the word count). A tolerance of +/- 10% applies.
• Format: Microsoft Word (.docx) or PDF. Handwritten submissions are not accepted.
• Font and spacing: 12-point Times New Roman or Arial; double line spacing throughout; 1-inch (2.54 cm) margins.
• Title page: Include your full name, student ID, course code and title, assessment title, date of submission, and lecturer name.
• Referencing: APA 7th Edition throughout. In-text citations are required for all claims, clinical data, and diagnostic criteria drawn from external sources. A minimum of eight (8) peer-reviewed references are required, with at least six (6) published between 2020 and 2026.
• Academic integrity: Your submission must be your own original work. All submissions are subject to similarity detection software. Refer to the university’s Academic Integrity Policy before submitting.
• Use of AI tools: Use of generative AI tools (e.g., ChatGPT) is not permitted for any part of this assessment. Any detected use will be treated as a breach of academic integrity.

5. Marking Criteria and Grading Rubric

This assessment is worth 30% of your final course grade. The total marks available are 100, mapped to the weighting below. Criteria are assessed holistically within each band.

6. Course Learning Outcomes

This assessment addresses the following MSN Program and NURS 6540 Course Learning Outcomes:

4. Perform a comprehensive and systematic advanced health assessment of the head, eyes, ears, nose, and throat, interpreting findings within a pathophysiological framework. (CLO 2)
5. Apply evidence-based clinical reasoning to formulate and prioritise differential diagnoses from complex, multi-system clinical data. (CLO 3)
6. Demonstrate advanced diagnostic reasoning by selecting and justifying appropriate investigations in response to clinical findings. (CLO 4)
7. Integrate interprofessional collaboration principles and structured clinical communication frameworks within the NP scope of practice. (CLO 5)
8. Apply person-centred, culturally responsive care principles in the clinical planning and management of diverse patient populations. (CLO 6)

7. Recommended Learning Resources

The following references are provided as starting points for your research. You are expected to search independently for current, peer-reviewed evidence to support your analysis. Additional relevant resources are available on the course LMS page under Week 6–8 materials.

Core Texts

• Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.
• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier Mosby.

Peer-Reviewed References (Suggested Starting Points)

• Weinreb, R. N., Aung, T., & Medeiros, F. A. (2019). The pathophysiology and treatment of glaucoma: A review. JAMA, 311(18), 1901–1911. https://doi.org/10.1001/jama.2014.3192
• Flaxman, S. R., Bourne, R. R. A., Resnikoff, S., Ackland, P., Braithwaite, T., Cicinelli, M. V., & GBD 2019 Blindness and Vision Impairment Collaborators. (2021). Global causes of blindness and distance vision impairment 1990–2020: A systematic review and meta-analysis. The Lancet Global Health, 5(12), e1221–e1234. https://doi.org/10.1016/S2214-109X(17)30393-5
• Lee, R., Wong, T. Y., & Sabanayagam, C. (2020). Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye and Vision, 2(1), 17. https://doi.org/10.1186/s40662-015-0026-2
• Warnakulasuriya, S., & Kerr, A. R. (2021). Oral submucous fibrosis: A review of the current management and possible directions for novel therapies. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 122(2), 232–241. https://doi.org/10.1016/j.oooo.2016.04.013
• Nij Bijvank, J. A., van Rijn, L. J., Balk, L. J., Tan, H. S., Uitdehaag, B. M. J., Petzold, A., & Theodorou, M. (2020). Diagnosing and quantifying a common deficit in multiple sclerosis: Internuclear ophthalmoplegia. Neurology, 92(20), e2299–e2308. https://doi.org/10.1212/WNL.0000000000007499

8. Sample Answer Guidance

NOTE: The following is a brief orientation to the type of analysis expected. It is not a model answer and is not sufficient on its own to meet the assessment criteria. Students are expected to develop a substantially more detailed, evidence-integrated, and referenced response.

In the case of Mr. Okafor, the constellation of a fixed and dilated left pupil, a hazy and steamy cornea, deep aching ocular pain rated 7/10, associated nausea and vomiting, and elevated intraocular pressure on palpation presents a classic clinical picture consistent with acute angle closure glaucoma — a true ophthalmic emergency requiring immediate intervention and specialist referral (Weinreb et al., 2019). The pathophysiological mechanism involves a sudden obstruction of the trabecular meshwork that impairs aqueous humor drainage, leading to a rapid and dangerous rise in intraocular pressure that, if untreated, risks permanent optic nerve damage and irreversible vision loss within hours.

The fundoscopic finding of cupping of the left optic disc further supports a diagnosis of glaucomatous change, as optic disc cupping reflects loss of retinal nerve fiber layers and is a well-established structural marker of glaucomatous damage (Flaxman et al., 2021). Concurrently, the presence of microaneurysms in the right fundus is a clinically significant finding that should not be overlooked — in a patient with a HbA1c of 9.1% and a decade-long history of type 2 diabetes, scattered microaneurysms in the macular region are pathognomonic of non-proliferative diabetic retinopathy, a finding that necessitates separate ophthalmological surveillance and improved glycaemic control. The oral mucosal lesions — raised, white, adherent plaques that cannot be rubbed off — meet the clinical criteria for leukoplakia, which carries a recognized precancerous potential and warrants urgent biopsy and specialist referral, particularly given the patient’s smoking history (Warnakulasuriya and Kerr, 2021).

Students are encouraged to structure their response using clear subheadings aligned to each part of the task, maintain an analytical rather than descriptive tone, and ensure every clinical claim is supported by a current, peer-reviewed citation. The marking rubric rewards specificity, evidence integration, and clinical reasoning sophistication — broad or unsupported statements will not achieve marks in the higher grade bands.

9. Academic Integrity Statement

By submitting this assessment, you confirm that the work is entirely your own, that it has not been submitted for credit in any other course, and that all sources have been properly acknowledged in accordance with APA 7th Edition. Suspected breaches of academic integrity — including contract cheating, collusion, plagiarism, or the unauthorized use of AI writing tools — will be investigated in accordance with the university’s Academic Integrity Policy and may result in a grade of zero for the assessment or course-level consequences. If you are uncertain about what constitutes academic integrity, contact your lecturer or academic skills advisor before submitting.