Question: Make A Nurse’s Progress Notes (FDARE) Based On This Case Scenario Informed Consent Case Scenario # 1 Patient AA Is A 26-year-old Female Undergraduate Who Was Seen In ENT Clinic In A Bacolod City Specialist Hospital With Complaints Of Nasal Discharge, Nasal Obstruction, Excessive Sneezing, Mouth-breathing, And Occasional Cough. Physical Examination Revealed …

Make a Nurse’s progress Notes (FDARE) based on this casescenario

Informed Consent Case Scenario # 1

Patient AA is a 26-year-old female undergraduate who was seen inENT clinic in a Bacolod City specialist hospital with complaints ofnasal discharge, nasal obstruction, excessive sneezing,mouth-breathing, and occasional cough. Physical examinationrevealed a young lady who was not pale, anicteric, and afebrile.Examination of the nasal cavity revealed normal shaped nose and noskin changes. There was an obvious pale, multiple polypoid bluishmass partially obliterating both nasal cavities which did not bleedon contact. The mass arises from the lateral wall; both turbinatesappear bluish and engorged with partial patency. Neckexaminationrevealed discrete submandibular and submental lymphnodes which were nontender.

An assessment of chronic rhinosinusitis with bilateral allergicnasal polyp was made on clinical ground. Patient had X-rays of theparanasal sinuses which revealed opacity of both maxillary sinusesand nasal cavities and this supported the above clinical findings.Patient could not afford computerized tomography due to financialchallenges.

The computerized tomographic scan is an important radiologicinvestigation that would have provided information on thepossibility of offering the patient endoscopic sinus surgery alongwith ethmoidectomy and sphenoidotomy and possibly surgery to thefrontonasal recess as the anatomy of the ethmoid and its immediaterelations will be known.

Other baseline investigations were done and found to be normal.The details of what surgery is going to be done was explained tothe patient in the clinic as well as the anaesthesia, the recoveryprocess, postoperative management, and complication that can arisefrom the surgery. She was admitted and a written informed consentwas signed by the patient and witnessed by a ward nurse afteranother round of discussion of the surgery about to beperformed.

Patient had endoscopic guided bilateral nasal polypectomy andintranasal antrostomy under general anaesthesia after counseling inthe clinic and a well-documented informed and understood consent.Ethmoidectomy, middle meatal antrostomy, and frontal recess surgerycould not be done as there was no computerized tomographic scanthat would assist in the anatomical guidance of this region.Patient was managed with antibiotics, decongestant, analgesics, andsteroid spray postoperatively.

Postoperatively before discharge patient expressed satisfactionat the outcome of surgery as both nasal cavities were clear andpatent. Six months after surgery, patient returned to the clinicwith recurrence of her former symptoms. She then claimed that shewas not well-informed about the possibility of recurrence and thechances for a total cure of the condition. Patient then wentthrough another period of counseling and information giving afterwhich she still refused to have repeat surgery.