Case Study Assessing The Head, Eyes, Ears, Nose, And Throat Assignment
Case Study Assessing The Head, Eyes, Ears, Nose, And Throat Assignment
Episodic/Focused SOAP Note Template
Patient Information:
Initials, R. T; Age 50 years; Sex Male; Race Not stated
SUBJECTIVE DATA.
CC: “I am here for nasal congestion and sneezing.”
HPI: The client, R. T is a 50yo who is presented to the clinic with nasal congestion, rhinorrhea, sneezing, and postnasal drainage. The client added struggling with an itchy nose, palate, eyes, and ears. He reveals that these symptoms have persisted for the past 5 days. The client reports taking Mucinex OTC the past 2 nights to be able to breathe while asleep. He claims that Mucinex OTC resulted in minimal improvement Case Study Assessing The Head, Eyes, Ears, Nose, And Throat Assignment.
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Current Medications: Mucinex OTC 600/30 mg orally once daily taken to enhance breathing.
Allergies: NO known medication, food, or environmental allergies.
PMH: Has no past major illnesses or surgeries.
Soc Hx: No details on social history.
Fam Hx: Family history not available.
ROS:
GENERAL: Denies fever, chills, weight change, night sweat, fatigue, or weakness.
HEENT: Denies head injuries. Reports itching eyes. Denies double or blurred vision. Reports itchy ears and palate. Reports nasal congestion, itchy nose, sneezing, rhinorrhea, and postnasal drainage. Denies swollen tonsils.
SKIN: Denies itching, discoloration, or skin rashes.
CARDIOVASCULAR: Denies chest discomfort, pain, or edema.
RESPIRATORY: Denies cough or sputum production.
GASTROINTESTINAL: Denies diarrhea, nausea, vomiting, or diarrhea. Denies constipation or abdominal pains
GENITOURINARY: Denies pain or burning on urination.
NEUROLOGICAL: Denies headache or numbness.
MUSCULOSKELETAL: Denies stiffness or joint pain.
HEMATOLOGIC: Denies bleeding or anemia.
LYMPHATICS: Denies enlarged nodes.
PSYCHIATRIC: Denies anxiety or depressive symptoms.
ENDOCRINOLOGIC: Denies heat or cold intolerance.
ALLERGIES: Denies history of rhinitis or asthma.
OBJECTIVE DATA.
Physical exam:
General: The client, R. T is a 50yo male. He is well-nourished, well-developed, well-groomed, presentable, and appropriately dressed for today’s weather and time of the year. He is attentive throughout the interview and responds to all interview questions correctly. She is alert and oriented to person, time, place, event, and situation. He appears in no acute distress. His affect and judgment are good and seems to be future-oriented.
Vital signs: T 97.9*F; B/P-119/67; HR-91 bpm; RR 18; Pulse Ox 95%; W 190lbs; H 6’2″ and BMI score of 24.5.
SKIN: Symmetrical face. A good elasticity skin turgor was noted.
HEENT:
Head: No nodules to the scalp.
Eyes: Equally round pupils on both eyes.
Ear: Normal external ear structures with clear canals.
Nose: Signs of the itchy nose seen. Boggy and pale nasal mucosa was noted. Clear thin secretions
noted. Enlarged nasal turbinates that seem to obstruct airway flow were noted.
Throat: No enlargement in tonsils. The throat is mildly erythematous.
Neck: No lymphadenopathy noted.
Chest/Lungs: Clear lungs.
Heart/Peripheral Vascular: No murmurs.
Abdomen: Active bowel sounds.
Genital/Rectal: Omitted
PV: No numbness to the lower extremities.
Musculoskeletal: Equal and strong bilateral hand grip noted.
Neurological: All extremities can move symmetrically.
Psych: No agitation or anxiousness with good mood and affect.
Diagnostic results:
Serum assay for IgE antibodies: IgE antibodies detected in the blood.
ASSESSMENT.
Differential Diagnoses
Based on health history and physical examination results, the client’s three differential diagnoses starting from the most likely to the list likely diagnosis are as discussed below.
- Allergic rhinitis (AR) – Primary diagnosis
- Viral or non-allergic rhinitis
- Acute Bacterial Rhinosinusitis
Allergic Rhinitis (AR) – Primary Diagnosis
Allergic rhinitis (AR) is the primary diagnosis for this client. AR is an atopic condition, which is characterized by sneezing, clear rhinorrhea, nasal congestion, and nasal pruritis (Watts et al., 2019). Other symptoms associated with this disease include itching the nose, eyes, throat, cough, fatigue, and postnasal drip (Small et al., 2018). Additionally, the nasal mucosa appears pale in color, swollen, and inflamed (Greiwe & Bernstein, 2019). According to Brozek et al. (2017), the prevalence of allergic rhinitis is high among people with asthma. The client reports most of these symptoms, including nasal congestion, rhinorrhea, sneezing, and postnasal drainage. He also reports an an itchy nose, palate, eyes, and ears. Therefore, allergic rhinitis qualifies to become the client’s primary diagnosis Case Study Assessing The Head, Eyes, Ears, Nose, And Throat Assignment.
Viral or Non-Allergic Rhinitis
Non-allergic or viral rhinitis or the “common cold is another potential diagnosis for this client. This disease is mainly characterized by serous nasal drainage and congestion, sneezing, fatigue, headache, sore throat, and itchy nose, roof of mouth, and eyes (Huang et al., 2018). Additionally, people with viral rhinitis report red and swollen nasal mucosa due to hyperemia. Other symptoms associated with this condition are a low-grade fever, chills, muscle aches, and a cough. The client might have viral rhinitis since he reports nasal congestion, rhinorrhea, sneezing, postnasal drainage, and itchy nose, palate, eyes, and ears. However, viral rhinitis is ruled out in this client due to the absence of significant symptoms, including a low-grade fever, chills, muscle aches, and a cough.
Acute Bacterial Rhinosinusitis
Acute Bacterial Rhinosinusitis is another potential diagnosis for this client. This condition is characterized by nasal congestion, facial pain, headache, inflammation in the nose, and excessive and thick mucus, filling sinus cavities (Ebell et al., 2018). The client might be having this condition since he reports serous nasal drainage and congestion, which are key symptoms of Acute Bacterial Rhinosinusitis. However, this disease is ruled out due to the absence of significant symptoms, including facial pain, headache, inflammation in the nose, and excessive and thick mucus.
References
Brozek, J, L., Bousquet, J., Agache, I., Agarwal, A., Bachert, C., Bosnic-Anticevich, S., et al. (2017). Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol. 2017; 140 (4):950–8.
Ebell, M. H., McKay, B., Dale, A., Guilbault, R., & Ermias, Y. (2019). Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. The Annals of Family Medicine, 17(2), 164-172. https://link.springer.com/chapter/10.1007/978-3-319-74835-1_11
Greiwe, J. C., & Bernstein, J. A. (2019). Allergic and mixed rhinitis: diagnosis and natural evolution. Journal of Clinical Medicine, 8(11), 1-7. Doi: 10.3390/jcm8112019.
Huang, Y., Zhang, Y., & Zhang, L. (2018). Prevalence of allergic and nonallergic rhinitis in a rural area of northern China based on sensitization to specific aeroallergens. Allergy, Asthma & Clinical Immunology, 14(1), 1-10. https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0299-9
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
Watts, A. M., Cripps, A. W., West, N. P., & Cox, A. J. (2019). Modulation of allergic inflammation in the nasal mucosa of allergic rhinitis sufferers with topical pharmaceutical agents. Frontiers in pharmacology, 10, 294. https://doi.org/10.3389/fphar.2019.00294
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 Case Study Assessing The Head, Eyes, Ears, Nose, And Throat Assignment.
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.
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CASE STUDY 1:
Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard 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
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.
You can find the episodic/focused note template Below.
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.
For Week 5, Assignment 1:
Please make up the information needed to do your Focused/Episodic Soap note.
To say N/A is not acceptable.
For ROS and PE, you do not have to Review all the systems, only the ones that are related to the CC. Always review and examine the Resp and CV system no matter the complaint.
**You will need to put in (MAKE UP) the missing information in the note (some of the information you will have to MAKE UP ie meds, hx, parts of the ROS and PE). I’m looking to make sure you know what information to include.
In the Assessment/Plan, you will document your differential diagnoses as per the assignment.
YOU WILL MAKE UP INFORMATION IN ORDER TO COMPLETE THE SUBJECTIVE AND OBJECTIVE INFORMTION
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe Case Study Assessing The Head, Eyes, Ears, Nose, And Throat Assignment.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Case Study Assessing The Head, Eyes, Ears, Nose, And Throat Assignment.