Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Emily, age 15, is brought to your clinic complaining of chills, aches, and a sore throat. Without any testing, consider all of the possible diagnoses. It could be a cold, the flu, bronchitis, or even something more serious, such as meningitis or mononucleosis. Assessing the actual cause will involve much more than simple visual inspection. Some conditions are so subtle that they require the use of special instruments and tests in addition to a trained eye and ear.
This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques in order to form accurate diagnoses.
Learning Objectives
Students will:
- Apply assessment skills to diagnose eye, ear, and throat conditions
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat
Learning Resources
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
· Chapter 11, “Head and Neck”
This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.
· Chapter 12, “Eyes”
In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.
· Chapter 13, “Ears, Nose, and Throat”
The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
· Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.
· Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.
· Chapter 25, “Nasal Symptoms and Sinus Congestion”
In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.
· Chapter 30, “Red Eye”
The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.
· Chapter 32, “Sore Throat”
A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
· Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.
Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
· Chapter 71, “Visual Function Evaluation: Snellen, Illiterate E, Pictorial
This section explains the procedural knowledge needed to perform eyes, ears, nose, and mouth procedures.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
· Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)
Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical examination. Vision Research 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217
Rubin, G. S. (2013). Measuring reading performance. Vision Research, 90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436
Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440.
Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging).
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)
Document: Midterm Exam Review (Word document)
Shadow Health Support and Orientation Resources
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Focused Exam: Cough (Word document)
Use this template to complete your Assignment 2 for this week.
Optional Resource
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
· Chapter 7, “The Head and Neck” (pp. 178–301)
This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck conditions.
Required Media
Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.
University of Iowa Ophthalmology. (2016, December 19). Fluorescein staining of the cornea. Retrieved from https://vimeo.com/198695974
Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from https://vimeo.com/198695974. The author(s) and publishers acknowledge the University of Iowa and EyeRounds.org for permission to reproduce this copyrighted material.
Note: Approximate length of this media program is 25 seconds.
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
To Prepare
- By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
- Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:
- Review this week’s Learning Resources and consider the insights they provide.
- Consider what history would be necessary to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
By Day 6 of Week 5
Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.(extension)” as the name.
- Click the Week 5 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 5 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn1+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 5 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 5 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 6 of Week 5
To participate in this Assignment:
Week 5 Assignment 1
Week 5 Assignment Sample Paper
NURS 6512 Week 5 Assignment – Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Episodic/Focused SOAP Note Template
Patient Information:
65 year Old AA male
S.
CC Chest pain.
HPI: The individual in this case is a 65 year Old AA male. The patient indicates that he developed an abrupt commencement of chest pain that commenced early in the morning. The patient indicates the pain as crushing and is ranked 9/10 in pain scale. The aching’s location is in the interior of the ribcage, and this is complemented by shortness of breath. On probing, the individuals indicated feeling nauseated. The individual has also tried medication such as antacid with negligible reprieve of his signs. The patient has a positive history of GERD and hypertension that have previously been controlled.
The patient also indicates the mother passed on at 78 of breast cancer, Father at 75 of CVA. The patient does not exhibit an account of untimely cardiac disease in first degree relations. The patient has been married for the last 39 years.
Location: Chest.
Onset: early in the morning.
Character: Crushing pain in the middle of the chest.
Associated signs and symptoms: nauseous without vomiting.
Timing: no sufficient information.
Exacerbating/ relieving factors: antacid with minimal relief of the symptoms.
Severity: 9/10 pain scale
Current Medications: antacids with minimal relief on the symptoms.
Allergies: No known allergies.
PMHx: positive history of GERD and hypertension is controlled.
Soc Hx: currently consumes moderate alcohol and negative for tobacco use.
Fam Hx: The mother passed on at 78 of breast cancer, Father at 75 of CVA. There is no account of untimely cardiac ailment in first degree.
ROS:
GENERAL: negative for fever, chills, fatigue.
HEENT: No evidence of HEENT examination.
SKIN: No evidence of skin examination.
CARDIOVASCULAR: negative for orthopnea, PND, positive for sporadic lower extremity edema.
RESPIRATORY: no evidence of respiratory examination.
GASTROINTESTINAL: positive for nausea without vomiting, negative for diarrhea, abdominal pain.
GENITOURINARY: not applicable.
NEUROLOGICAL: no evidence of neurological examination.
MUSCULOSKELETAL: no evidence of musculoskeletal examination.
HEMATOLOGIC: no evidence of hematologic examination.
LYMPHATICS: no report of lymphatic examination.
PSYCHIATRIC: no report of psychiatric examination.
ENDOCRINOLOGIC: no report of endocrinologic examination.
ALLERGIES: no report of allergies.
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
Physical exam: The results of electrocardiography (EKG), chest radiograph (CXR), and CK-MB test, indicate that the lungs are clear to auscultation and percussion bilaterally. The Pt looks diaphretic and restless. PMI is in the 5th inter costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is perceived best at the second right inner costal space that discharges to the neck. A third heart sound is heard at the Apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+LE edema is noted.
The abdomen is proportioned devoid of distention, bowel noises are ordinary quality and concentration in all parts, a bruit is heard in the right para umbilical area. No masses or splenomegaly are eminent. Positive for mid-epigastric inflammation with profound palpation. The lungs are flawless to auscultation and percussion jointly.
Diagnostic results: EKG, CXR, CK-MB.
A.
Differential Diagnoses
The physical exam comprises of an active observational examination of the individual. According to Balogh, Miller, and Ball (2015), the nurse should first observe the patient’s behavior, complexion, posture, level or distress, and any other signs which might contribute to the understanding of the health of the patient. A physical exam can include the entire HEENT examination, which can assist the nurse to enhance the steps taken in the diagnostic process. In the long run, this can avert unnecessary diagnostic testing and build trust with the patient (Balogh, Miller & Ball, 2015). Some of the physical examinations that should be conducted on the patient can include the following.
First, inspection where the clinician can look at or inspect specific areas for abnormalities. Second, palpation where the nursing practitioner can use their hands to feel for abnormalities during the health assessment (“Techniques of Physical Assessment: NCLEX-RN”, 2020). In the basic HEENT examination, the nursing practitioner can commence by checking for any deformities or asymmetry. After completing the head, the clinician should proceed to the eyes, ears, nose, and mouth. In checking the eyes, the nurse should assess for eye movement (Haber et al., 2015). For this patient experiencing chest pains, one of the most recommended tests is the ECG/EKG, CXR, CK-MB test that can determine if the patient suffers from a heart-related issue (Chamley, Holdsworth, Rajappan & Nicol, 2019).
Based on the symptoms depicted by the patient, they most probably have the following illnesses.
GERD: GERD is also known as gastroesophageal reflux disease. The patient has a past history of GERD. GERD is chronic acid reflux, and it makes the patients experience pain in the chest.
Hypertrophic cardiomyopathy: this occurs when the heart grows too thick because of genetic factors (Marian & Braunwald, 2017). The thickening of the heart can can prevent blood from flowing from the heart properly. Some of the symptoms include chest pains, shortness of breath, and dizziness.
Myocardial ischemia: occurs when there is little blood flow to the heart muscles, thereby preventing the heart from receiving enough oxygen (Heusch, 2016). Some of the symptoms of myocardial ischemia include shortness of breath and pain in the chest.
Pulmonary embolism: this entails the blockage of the pulmonary arteries in the lungs. It is caused by blood clots that travel to the lungs from deep veins in the legs. Some of the symptoms include shortness of breath and chest pain.
Chronic obstructive pulmonary disease (COPD): this is a chronic inflammatory lung disease that causes obstructed airflow from the lung (Qureshi, Sharafkhaneh & Hanania, 2014). COPD also has distinct symptoms that cause shortness of breath and chest pain.
For the nursing practitioner to understand the root cause of the pain in the chest this necessitates an ECG test that can check all the underlying patient conditions.
References
Balogh, E., Miller, B., & Ball, J. (2015). The Diagnostic Process. Retrieved 26 December 2020, from https://www.ncbi.nlm.nih.gov/books/NBK338593/
Chamley, R., Holdsworth, D., Rajappan, K., & Nicol, E. (2019). ECG interpretation. European Heart Journal, 40(32), 2663-2666. doi: 10.1093/eurheartj/ehz559
Haber, J., Hartnett, E., Allen, K., Hallas, D., Dorsen, C., & Lange-Kessler, J. et al. (2015). Putting the Mouth Back in the Head: HEENT to HEENOT. American Journal Of Public Health, 105(3), 437-441. doi: 10.2105/ajph.2014.302495
Heusch, G. (2016). Myocardial Ischemia. Circulation Research, 119(2), 194-196. doi: 10.1161/circresaha.116.308925
History & Physical Exam | SEER Training. (2020). Retrieved 26 December 2020, from https://training.seer.cancer.gov/diagnostic/history.html
Marian, A., & Braunwald, E. (2017). Hypertrophic Cardiomyopathy. Circulation Research, 121(7), 749-770. doi: 10.1161/circresaha.117.311059
Qureshi, H., Sharafkhaneh, A., & Hanania, N. (2014). Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Therapeutic Advances In Chronic Disease, 5(5), 212-227. doi: 10.1177/2040622314532862
Techniques of Physical Assessment: NCLEX-RN. (2020). Retrieved 26 December 2020, from https://www.registerednursing.org/nclex/techniques-physical-assessment/
Assignment 2: Digital Clinical Experience: Focused Exam: Cough
In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
To Prepare
- Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Focused Exam: Cough Assignment:
Complete the following in Shadow Health:
- Respiratory Concept Lab (Required)
- Episodic/Focused Note for Focused Exam: Cough
- HEENT (Recommended but not required)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 5
- Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
- Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.
- (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
- Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
- Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.
Grading Criteria
To access your rubric:
Week 5 Assignment 2 DCE Rubric
Submit Your Assignment by Day 7 of Week 5
To submit your Lab Pass:
Week 5 Lab Pass
To participate in this Assignment:
Week 5 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement Form:
Submit your Week 5 Assignment 2 DCE Student Acknowledgement Form
What’s Coming Up in Week 6?
Next week, you will evaluate abnormal findings in the area of the abdomen and the gastrointestinal system. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system as you complete your Lab Assignment in assessing the abdomen in a SOAP note format. You will also take your Midterm Exam, which covers the topics in Weeks 1–6. Please review the previous weekly content and resources to help you prepare for your exam. Plan your time accordingly.
Week 6 Required Media
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Lab Assignment. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Assignment on time.
Next Week
To go to the next week:
Week 6
PLACE THIS ORDER OR A SIMILAR ORDER WITH NURSING PAPERS MARKET TODAY AND GET AN AMAZING DISCOUNT
