NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
Focused SOAP Note for a patient with chest pain
CC: “nasal congestion and rhinitis * 5 days”
HPI: The patient is a 50-year old person who presented to the clinic suffering from rhinorrhoea, nasal congestion, postnasal drainage as well as sneezing. The patient has struggled with the itchy palate, nose, as well as eyes for a period of 5 days. Moreover, he suffers from a pale, boggy nasal mucosa alongside enlarged turbinate as well as clear thin secretions. The tonsils are not enlarged; though, he has mild erythematous in his throat.
PMH: No significant medical history. The patient denies having been admitted or undergoing surgical intervention in the last 2 years. He is up to date on his immunization.
FH: Both of the patient’s parents are alive. The patient is married and they have two children aged 14
and 12. He has two siblings who are aged 42 and 46 years. They are all healthy, except the mother who presents with breast cancer.
SH: The patient denies smoking. He indicates that he quit smoking in 2006. On the other hand, he occasionally drinks alcohol. The patient engages actively in religious activities. The patient understands the importance the eating healthy and engaging in regular physical exercise.
Allergies: NKDA, indicates seasonal allergic reactions.
The general-The patient is well-groomed and oriented. He denies fever or fatigue. He is AAOX 4.
HEENT: The patient denies headache, but the eyes are itchy and red. There are no changes in the visual acuity. The tympanic membranes are intact with no hearing changes. The patient has nasal congestion and itchy nasal mucosal. The nasal turbinate is also enlarged.
Cardiovascular–Negative chest pain, no palpitations.
Gastrointestinal– No nausea, non-distended abdomen.
Pulmonary– negative for dyspnea or hemoptysis. NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
VS: BP 121/82; P 67; R 20; T 97.8; 02 96% Wt 191lbs; Ht 70”
General-The patient denies weakness or fatigue. He is well-groomed and nourished.
Cardiovascular- No chest pain or cyanosis noted in the patient.
HEENT: Eyes are itchy and red. The tympanic membranes are intact with no discharge. No tonsillitis or purulent discharge was produced. The throat is moderately erythematous. Enlarges nasal turbinate with clear thin secretions.
Gastrointestinal-The abdomen is symmetrical and non-distended.
Pulmonary– Lungs are clear to auscultation, no chest pain or murmuring sound produced.
Diagnostic results: Skin test positive for allergy, Allergen-specific IgE antibody test not done.
- Allergic rhinitis: The condition is characterized by sneezing and nasal congestion. The condition result from inhalation of allergens. Most of the symptoms indicated by the patient are consistent with the allergic rhinitis and this could be the most possible diagnosis (Hoyte & Nelson, 2018).
- Sinusitis: The condition is characterized by the inflammation of the sinuses due to bacterial or viral infection. The common symptoms of the disease include nasal congestion, itchiness, and reddening. Also, the patient may have facial pain and pressure (Almutairi et al., 2018).
- Common cold: Common cold is caused influenza virus. The virus is limited to the sinuses and is mainly spread through contact. The symptoms include nasal congestion, fever and headache (Singh et al., 2017). The patient denied fever and headache in this case.
- Administer nasal corticosteroids with oral antihistamine (Urrutia Pereira, 2018).
Almutairi, M. B., Alsulaimi, S. M., Alghamdi, R. A., Alrehaili, K. A., Habhab, S. A., Althagafi, A. M., Alghamdi, F. A., Meighrbl, N. A., Alsuhaymi, W. M., & AlYahya, M. S. (2018). Evaluation of GERD diagnosis, management, and outcomes. The Egyptian Journal of Hospital Medicine, 72(9), 5195-5202.
Hoyte, F. C., & Nelson, H. S. (2018). Recent advances in allergic rhinitis. F1000Research, 7, 1333.
Singh, M., Singh, M., Jaiswal, N., & Chauhan, A. (2017). Heated, humidified air for the common cold. Cochrane Database of Systematic Reviews.
Urrutia Pereira, M. (2018). Knowledge of pharmacists about allergic rhinitis and its impact on asthma guidelines (Aria guidelines): A comparative Brazilian/Paraguayan pilot survey.
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Episodic/Focused SOAP Note Template
Initials: L.M Age: 20 years old Sex: Female Race: Caucasian
CC (chief complaint): “Sore throat.”
HPI: Lily is a 20-year-old Caucasian female patient who came to the clinic complaining of a sore throat that had lasted for the past three days. The patient was taking the sore throat lightly until when there was a flu outbreak at her college about two weeks ago when she got concerned that this incident might be associated with her symptoms. The patient also reported additional symptoms such as headache, pain with swallowing, and decreased appetite. She claims that some of her classmates presented with similar symptoms. She however denies chills or fever. She has not taken any medication for her present condition.
Onset: 3 days ago
Character: scratchy and sore.
Associated signs and symptoms: decreased appetite, headache, running nose, and pain with swallowing
Timing: Started two weeks after a flu outbreak at her school.
Exacerbating/ relieving factors: swallowing food or drinking water worsens the pain. Gargling with warm water reduces the pain.
Severity: 6/10 pain scale
Current Medications: Multivitamin oral tablets, once daily for the past 6 months.
Allergies: Dust mite. No drug or food allergies.
PMHx: Immunization status is up to date, with the last flu vaccine received in October 2020. Her last tetanus shot was received in June 2019. The patient denies any history of medical diagnosis or surgery.
Soc Hx: The patient is a full-time college student studying economics. She enjoys spending time with his friends and reading comic books. She denies taking alcohol, cigarettes, or any other illicit drug of abuse.
Fam Hx: Patient mother has a history of diabetes and hypertension. His father was diagnosed with Gout. Her paternal grandfather died at the age of 65 years from stroke, with a history of diabetes. Her paternal grandmother is still alive with a history of HTN, and osteoarthritis. She has no information regarding her maternal grandparents.
GENERAL: No weight loss, chills. Report fever, weakness, and fatigue. Reports decreased appetite.
HEENT: Head: Reports headache. No signs of trauma or injury. Eyes: No vision changes or double or blurry vision. The sclera has no abnormal discoloration. Ears: No hearing loss. Nose and throat: congestions, or sneezing. The patient complains of a sore and scratchy throat. The patient also reports pain with swallowing that she rates as a 6/10 severity on a pain scale for the past 3 days.
SKIN: No itchiness or rashes.
CARDIOVASCULAR: No chest pressure, pain, or any other discomfort. No edema or palpitations.
RESPIRATORY: Report shortness of breath and cough. No sputum
GASTROINTESTINAL: No nausea or vomiting, anorexia, or diarrhea. No abdominal pain.
GENITOURINARY: No burning on urination, hesitancy, no urgency, no foul odor or urine color.
NEUROLOGICAL: Reports intermittent headache for the past 3 days.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness
HEMATOLOGIC: No bruises, anemia, or bleeding.
LYMPHATICS: No history of splenectomy. Swollen lymph nodes were noted in the neck
PSYCHIATRIC: No history of anxiety or depression. Denies any history of harming self or others.
ENDOCRINOLOGIC: No reports of sweating, heat, or cold intolerance. No polydipsia or polyuria.
ALLERGIES: Dust mites
General: The patient is alert and cooperative all through the examination period. She displays no signs of distress. Her vitals are T: 98.6, Pls: 85, RR: 19, BP: 105/78, and O2 99% on room air.
HEENT: Head is atraumatic and normocephalic. Pupils are round, equal, and reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. Throat with mild swelling and exudates. Tonsils are swollen. Nostrils are red and swollen.
Chest/lungs: Breathing sounds clear to auscultation
Heart: Regular heart rate and rhythm with no murmur or gallop.
Abdomen: Soft, non-distended, non-tender abdomen, with bowel sounds present in all four quadrants.
Neurological: Intermittent headache.
Diagnostic results: Complete Blood Count (CBC) 7.9: Red Blood Cells 4.7, Platelets 200, and H/H: 12.6/37.8. Throat swab culture ordered with preliminary findings reveal negative results of Group A streptococcus bacteria.
- Influenza: This is a viral infection that affects the lung characterized by upper respiratory symptoms. Patients diagnosed with this condition normally present with several signs and symptoms such as cough, fever, malaise, headache, coryza, respiratory distress, and sore throat (Chow et al., 2019). The patient in the provided case study displays most of these symptoms making it the most appropriate diagnosis. Additionally, the patient might have been infected with the virus during the flu outbreak. However, a throat culture is needed to confirm the presence of the influenza virus.
- Acute Pharyngitis: Acute pharyngitis is a medical condition affecting the tonsils or posterior pharynx caused by microorganisms. Common symptoms displayed include sore throat, dysphagia, fever, headaches, abdominal pain, and fetid breath (Sykes et al., 2020). This condition is normally associated with acute pharyngitis. Some of the symptoms were displayed by the patient. However, no signs of abdominal pain, among others were not displayed by the patient.
- Acute epiglottitis: This is a severe and rapidly progressing health condition characterized by sore throat, dyspnea, and hoarseness caused by Hemophilus influenza infection (Baird et al., 2018). The patient displayed most of these symptoms, however, a throat culture is needed to confirm this diagnosis.
- Acute Sinusitis: This is a bacterial infection characterized by paranasal sinuses. Symptoms include fever, headache, nasal discharge, congestion, and cough that can occur suddenly and become worse over a few days (Ebell et al., 2019). All of these symptoms, some of these symptoms, or even none of these symptoms may occur in individuals with sinusitis, just like the patient in the provided case study.
- Laryngitis: This is an inflammation of the larynx that can either be non-infectious or infectious. The most common symptoms associated with laryngitis include hoarseness, voice fatigue, throat pain, a sensation of lumping in the throat, and cough (Lechien et al., 2018). The patient in the provided case study displayed most of these symptoms. However, he also reported a running nose which is not experienced with this diagnosis.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Baird, S. M., Marsh, P. A., Padiglione, A., Trubiano, J., Lyons, B., Hays, A., … & Phillips, D. (2018). Review of epiglottitis in the post Haemophilus influenzae type‐b vaccine era. ANZ journal of surgery, 88(11), 1135-1140.
Chow, E. J., Doyle, J. D., & Uyeki, T. M. (2019). Influenza virus-related critical illness: prevention, diagnosis, treatment. Critical care, 23(1), 1-11.
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://doi.org/10.1370/afm.2354
Lechien, J. R., Saussez, S., & Karkos, P. D. (2018). Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018. Current opinion in otolaryngology & head and neck surgery, 26(6), 392-402. doi:10.1097/MOO.0000000000000486
Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257. PMCID: