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Documentation of Problem-Based Assessment of the Nose, Throat, Neck, and Regional Lymphatics

Subjective Findings

A 17-years old male and a college student seeks medical attention after feeling unwell for the past two days. His father accompanied him, and the patient complained of throat pain and drainage from his nose. Markedly, the patient states that he has been in good health until two days ago when he started feeling a burning pain in his throat which worsens when he swallows. He also complains of drainage from the nose, causing him a constant need to clear his throat. Since yesterday, he has not been able to eat well because of increased throat pain. However, his father says that the patient has been using throat lozenges and acetaminophen for the last two days to relieve pain. He states that he was exposed to dust four days ago, asserting that he is allergic to dust. Notably, allergies to dust can cause throat pain that can be complicated by drainage from the nose. The patient notes that he feels irritation, scratchiness, and burning sensation in his throat and a queer rasp in his voice. He also complains of high fever, chills, appetite loss, and swelling in the neck. Besides, he asserts that he experiences severe pain, continually unable to engage in his everyday activities.

Objective Findings

The patient has a rapid heart rate of 110 beats per minute and a 120/80 mmHg blood pressure level. Markedly, today he has a high fever of 39 degrees Celcius. His height is 176 centimetres, while his weight is 128 lbs. His skin is pale, accompanied by rashes on the neck and chest. He also has sore, swollen glands in his neck, and the throat has swollen red tonsils. He has a muffled voice, making him unable to speak clearly. Besides, he has white patches in the back of the throat. The gastrointestinal assessment shows ten bowel sounds per minute, no tenderness, negative spleen, and no organomegaly. He has a confusing level of consciousness, making it difficult for him to reason, provide medical history, and participate fully in medical examination.

Potential Risk Factors

Based on the assessment findings, one potential risk factor for throat pain is Allergic pharyngitis and postnasal drip. Typically, allergic pharyngitis, a throat inflammation, primarily results from an allergen that enters the mouth or nose. The patient indicates that he is allergic to dust. Therefore, he might have been exposed to this allergen when his nose was stuffed up, making him use his mouth for breathing. Consequently, the tissue dried out, leading to scratchy, irritating, and painful feelings. The patient also complained of having drainage from the nose, commonly known as postnasal drip, where the mucus flows from his nasal passage to the back of his throat. If the mucus had infections, this drainage could have caused the inflammation of the tonsils and the throat and made him feel like he had a lump in the back of his throat.

Additionally, environmental settings is also a lifestyle risk factor for throat pain. Markedly, infections can easily be transmitted in places where many people interact, particularly in institutions. The patient is a college student, implying that he is in contact with different people at school. Therefore, he is susceptible to colds and infections that may cause throat pain due to being in groups with other college students.


CDC. (2021, May 7). Suffering from a sore throat? Centers for Disease Control and Prevention.


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