Assessing The Head, Eyes, Ears, Nose, And Throat SOAP Note
Assessing The Head, Eyes, Ears, Nose, And Throat SOAP Note
ENT SOAP Note
Patient Information
Name: Charlotte Age: 28 years Sex: Female
Subjective
Chief Complaint: Runny nose, itchy eyes, and ears feel full
History of Present Illness (HPI)
The patient is a 28-year-old female who presented with itchy eyes and runny nose symptoms that started nine days ago. The symptoms are described as clear mucus. The patient rates the intensity of the itchiness as 10/10, claiming that they itch so much that she wishes to remove them. Sometimes, she has a tingly feeling in her throat. The patient experiences these symptoms every spring and took Claritin during the last episode in the previous year, which relieved the symptoms Assessing The Head, Eyes, Ears, Nose, And Throat SOAP Note.
ORDER HERE A PLAGIARISM FREE PAPER HERE
Current Medications: None
Past Medical History: The patient experiences itchy eyes, runny nose, and full ears every spring, and the symptoms last about a month and a half to two months.
Family History: Mother has hypertension, and father recently passed away from cardiovascular disease. There are no history of ear, nose, and throat (ENT) conditions within the patient’s immediate family.
SH: The patient is a stay-at-home mom living in a house with smoke detectors. No history of tobacco use, occasional alcohol use, married for two years
Allergies: pollen allergy, no known food allergies
Immunizations: Up to date on immunizations, first covid-19 vaccine 1/23/2021 Pfizer; 2nd Covid vaccine 2/23/2021 Pfizer
Review of Systems
General; denies fever and chills
Skin: negative for itchiness or rash
HEENT; Eyes: Confirms severe itching and denies vision loss, yellowing, blurred, or double vision
Ears, Nose, and Throat: Confirm running nose and discomfort in the throat and denies congestion, sneezing, and hearing loss.
Respiratory: no cough, sputum, angina, or dyspnea
Neurological examination was negative for headache, ataxia, dizziness, tingly feeling in arms and legs, paralysis, or changes in bladder control.
Genitourinary: Last Monthly Period (LMP): 26th June 2022, denies pregnancy burning sensation or itching during urination.
Musculoskeletal: negative for joint or muscle pain or stiffness
Hematological: no history of bleeding or anemia
Lymphatic: negative for inflamed spleen, positive for inflamed lymph nodes at the neck.
Psychiatric: The patient is well dressed, coherent in speech, follows the conversation well, and denies depression or anxiety.
Endocrinological: No history of polyuria or polydipsia, extreme heat or coldness except during the last trimester of her most recent pregnancy.
Cardiovascular: negative for chest pain, palpitations, pressure, edema, or discomfort
Objective
Physical Examination:
Vital Signs: Blood Pressure (BP) 186/102; Pulse Rate 70 bpm; Respiratory Rate 16; Body Temperature 98.6 Weight 119lbs; Height 5 feet, five inches.
General: The patient appears stressed about the recurring nature of the condition. She rubs her nose and eyes constantly due to the discomfort.
Ears: The ears appear normal. The health professional assesses for eustachian tube blockage through the pneumatic otoscope, as the patient complains of filled ears. The health professional also checks for fluid in the eardrum through the Valsalva maneuver. The technique entails instructing the patient to blow out the nose while applying pressure by holding it shut. The examination confirms fluid-filled ears.
Eyes: Eyelids appear swollen due to rubbing
Nose: The patient tends to breathe with the mouth due to a congested nose. The nose is congested due to excessive mucus production. Upon examination with a speculum, the nasal mucosa appears blue, pale, and swollen. An endoscopic examination found no polyps or other structural deformities (Small et al., 2018).
Face: The sinuses feel tender upon palpation, and the patient expresses facial discomfort. The face appears elongated due to continuous mouth-breathing.
Throat: posterior drainage of mucus was observed.
Neck: Swollen lymph nodes
Diagnostic Tests
Although the patient history and physical diagnosis point to an allergic rhinitis diagnosis, confirmatory diagnostic tests are required. The health professional suspects that the patient develops an allergic reaction to pollen every spring and orders the skin prick test. The test involves introducing the commercial allergen, in this case, pollen, into the skin’s epidermis by pricking the skin. Within 20 minutes, the patient responded to the prick with a typical allergic reaction characterized by a blanched wheal, redness, heat, and inflammation at the prick site. This test yields immediate results, helpful in ruling out conditions with similar symptoms. The health professionals requested an alternative allergen-specific IgE assay to test the patient reaction to the pollen in vitro Assessing The Head, Eyes, Ears, Nose, And Throat SOAP Note.
Assessment
Differential Diagnosis
- Viral Rhinitis
The patient’s symptoms may be confused for viral rhinitis, also known as the common cold. For example, a viral rhinitis patient may present with a runny nose, headaches, irritated throat, itchy eyes, and filled ears. However, this condition has been ruled out because Charlotte denied feeling chills and joint and muscle aches, and her body temperature fell within the normal limits, yet viral rhinitis usually causes low-grade fever (Ohio State University, 2019). Moreover, the common cold’s chief complaint would be a runny nose and throat irritation, whereas the chief complaint, in this case, was itchy eyes. Further, upon physical examination, the health professional identified a pale blue nasal mucosa instead of red, as would have been the case in viral rhinitis. Finally, viral rhinitis lasts between 1 to 2 weeks while the patient experiences the symptoms between 1,5 and 2 months every year, a description more consistent with allergic rhinitis.
- Acute Bacterial Rhinosinusitis
The patient’s condition may be misdiagnosed as acute bacterial rhinosinusitis because its clinical presentation is consistent with some symptoms. For example, the patient may experience nasal congestion and tender sinuses upon palpation. However, a professional will rule this condition out because the mucus has a thick consistency and is green or yellow in contrast with the clear runny mucus observed in Charlotte’s case (Ohio State University, 2019). Further, the patient’s symptoms are not accompanied by fever, muscle ache, and fatigue, and she has not reported the worsening of symptoms over time.
- Immotile Cilia Syndrome
Patients with conditions endure frequent respiratory infections due to the impaired structure and function of respiratory cilia. These anatomical structures are responsible for moving mucus, dust particle, and microorganisms within the tract, and impaired function is characterized by excessive mucus production, nasal congestion, difficulty in breathing, and ear infections. While these symptoms are similar to the patient’s clinical presentation, the health professional will rule out this condition because it begins in infancy (Ohio State University, 2019). Moreover, the symptoms may occur at any time of the year, unlike the patient’s description.
- Adenoid Obstruction
Patients with condition may present with nasal congestion that predisposes them to oral breathing. They also present with eustachian tube blockage (Singh eat al., 2017). This presentation is partially consistent with Charlotte’s description but will be ruled out because the endoscopy found no structural abnormalities. Moreover, the chief complaint in Charlotte’s case is itchy eyes while adenoid obstruction is primarily associated with sleep apnea.
- Primary/presumptive diagnosis: the primary diagnosis is allergic rhinitis because the history and clinical presentation agree with the disease’s description. The patient presents with filled ears, runny nose, itchy eyes, and throat irritation which lasts for about two months every year and disappears in response to environmental stimuli, confirmed through diagnostic tests to be pollen grains.
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.
***Assigned Case Study for assignment:
Focused Nose Exam
A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeksâ€. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
References
Ohio State University. (2019). Allergic Rhinitis. OSU. https://u.osu.edu/allergicrhinitis2019/differential-diagnosis/
Singh, I., Jain, A., Prasad, P., & Rajpurohit, P. (2017). Adenoid Hypertrophy in Adults: An Underdiagnosed Entity?. Archives of Otolaryngology & Rhinology, 3(1), 006-008. https://www.peertechzpublications.com/Otolaryngology-Rhinology/AOR-3-133.php
Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy, asthma & clinical immunology, 14(2), 1-11. https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0280-7 Assessing The Head, Eyes, Ears, Nose, And Throat SOAP Note
| Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain ORDER A PLAGIARISM FREE PAPER NOWS. HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.
Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
Allergies: PCN-rash; food-none; environmental- none
Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna ROS O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard 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. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) Assessing The Head, Eyes, Ears, Nose, And Throat SOAP Note
A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
|
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
- This section is not required for the assignments in this course (NURS 6512) but will be required for future courses Assessing The Head, Eyes, Ears, Nose, And Throat SOAP Note.