Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment

Episodic/Focused SOAP Note Template

Patient Information:

Initials, RB.

Age 50, Sex

Male, Race. Caucasian

Subjective

CC (chief complaint); nasal congestion and itchy eyes, nose, and palate for five days

HPI: Mr. Brown is a 50-year-old white male presenting with a complaint of nasal congestion, sneezing, rhinorrhea, nasal drainage, itchy nose, eyes, and palate for five days. He states that he has been taking Mucinex for the past two nights with minimal relief. He denies a headache or pain.

Current Medications:

Mucinex OTC at bedtime

Hydralazine 25mg TID

Allergies: NKDA

-reports seasonal allergies

-denies environmental allergy

PMHx: has a history of hypertension. Denies other illnesses. Immunizations are up to date; he received a flu shot this season. He Received a Tetanus booster last year. Hospitalized in 2018 for left femur fracture repair from a fall. No other significant medical or surgical history

Soc Hx: Mr. Brown lives in a one-story single-family home with his wife and three children. He has his master’s degree in business administration and works in a consulting firm where he has worked for 15 years. He is a former smoker, smoked cigarette from 17-38 years, and marijuana from the age of 18-30. He drinks socially about 1-2 drinks weekly. He states that he does not exercise but takes a walk around the neighborhood about three times weekly. He is a Christian and sometimes attends church on Sundays if he is not too tired. His wife is a beautician who enjoys making healthy meals for the family.

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:

-Father has a history of hypertension and BPH

-Mother died at 78 from a stroke.

-Two sisters with no significant medical history

-Three children aged 15, 17, and 20 with no significant medical history.

-Maternal Grandparents died from a car accident when he was 18. He does not remember their ages at death.

-Paternal grandparents are deceased, but he doesn’t remember the ages and cause of death

ROS:

GENERAL: Alert and oriented to person, place, situation, and time. Denies recent weight changes. Denies fatigue, fever, chills, and weakness.

HEENT: Denies headache. Eyes are itchy and red. No visual loss, blurred vision, double vision or yellow sclerae. States that Ears are itchy, erythematic, and inflamed, denies hearing loss and discharge from the ear. The nose is itchy with sneezing, congestion, and runny nose. Clear nasal discharge. Reports sore throat. Denies difficulty swallowing.

SKIN: No changes in pigmentation. No discoloration, moles, rash, or itching. Denies any other skin abnormalities.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath or cough

GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or discomfort. Reports regular daily bowel movements.

GENITOURINARY: Denies burning or pain on urination. Denies urinary tract infection.

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, fatigue, or stiffness.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema or rhinitis. Reports seasonal allergies.

Objective

Physical Exam: 

General: Alert and oriented to person, place, situation, and time. Appears well groomed and nourished. Eyes are itchy and red. PERRLA

V/S: Temp: 97.9 degrees Fahrenheit, Pulse:72 beats per minute and regular. Resp:18 beats per minute, Blood Pressure: 141/76, weight: 185 pounds Height: 68 inches

HEENT: Head is normocephalic. Eyes are itchy and red, with no discharge noted in eyes. No vision changes. Ears are red and inflamed. Nasal mucosa is pale and edematous with enlarged nasal turbinate. Clear thin secretions noted in nasal cavities. The throat is mildly erythematous, with no purulent discharge or bleeding noted. Tonsils are symmetrical and pink, no swelling noted.

NECK: Trachea in the midline, no deviation noted. No swollen Lymph nodes noted.

CARDIOVASCULAR: No palpitations or edema. Bilateral radial and dorsalis pedis pulse 2+ and regular.

RESPIRATORY: No shortness of breath, cough, or sputum noted. Lung sounds are clear anteriorly, posteriorly, and laterally. Respirations are even and unlabored.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

Diagnostic results:

  1. Allergy Skin tests: This can be done for this patient in this scenario. The test is done by introducing an allergen into the body intradermally to determine if there is an immune reaction (Nelvis, 2016). This test will help diagnose allergic rhinitis and determine what allergen the patient is reacting to (Health Quality Ontario, 2016). In this case, the patient tested positive for pollen, hence indicative of allergic rhinitis.
  2. Radioallergosorbent test : (RAST) is an antibody blood test that can be performed in this scenario. Testing for immunoglobulin E antibody in the blood will help determine if there has been an immune response; this is because the body produces antibodies in response to allergens (NHS, 2016).
  3. Sinus CT scan: A Sinus CT scan can be performed to rule out Sinusitis. CT scan of the sinus will reveal inflammation of the sinuses (Alam, 2020).
  4. Throat culture: A sputum culture can be performed to test for the presence of infectious microorganisms in the throat that may be responsible for an upper respiratory tract infection (Arberfeville et al., 2018). The test is done by swabbing the back of the throat after which the secretions are cultured, the test result for a throat culture takes days but is effective in identifying the presence of microorganisms in the upper respiratory tract and in this scenario may be useful in diagnosing tonsillopharyngitis.

 

Differential Diagnoses

  1.  Allergic Rhinitis:  Allergic rhinitis is an allergic response characterized by sneezing, itchy, watery eyes, congestion, and clear nasal discharge in response to exposure to allergens such as dust, chemicals, or pollen (American College of Allergy, Asthma & Immunology, 2015). When allergens are inhaled, it triggers an immunoglobulin E (IgE) mediated reaction, which then causes the symptoms (Wheatley & Alkis, 2015). This is the most likely diagnosis due to the positive skin test for pollen allergen and the presenting symptoms.
  2. Nonallergic Rhinitis: Nonallergic rhinitis is the inflammation of the nasal tissues causing sneezing, congestion, and runny nose. It is not caused by allergens rather by a build of fluid due to inflamed blood vessels due to viral infections, hormonal imbalances, or environmental factors (NHS, 2019). It is often diagnosed with history, negative tests for allergens, and a lack of improvement when treated like allergic rhinitis (NHS, 2019). Nonallergic rhinitis is a possible diagnosis for this patient; however, the presence of a positive pollen test suggests that allergic rhinitis is a more likely diagnosis. This patient also has itchy eyes, nose, and throat, which are symptoms more suggestive of allergic rhinitis.
  3. Sinusitis: Sinusitis is the inflammation of the tissue lining the sinuses due to viral, bacteria, fungal infections, or allergic reactions. When Sinusitis occurs, the sinus becomes filled and is unable to drain due to sinus blockage. Sinus blockage may be caused by smoking, weakened immune system, structural problems with the sinus, or following a cold (CDC, 2019b). It is characterized by cough, congestion, purulent rhinorrhea, facial pain, or pressure; It is sometimes accompanied by headache, malaise, and fever (Marvin, 2017). Symptoms usually diagnose it; however, a sinus CT scan may be used to ascertain the extent of infection if it persists (CDC, 2019b). Although there are similar symptoms such as congestion and rhinorrhea, Sinusitis is a less likely diagnosis in this scenario because rhinorrhea in Sinusitis is often purulent. This patient also lacks pertinent symptoms such as headaches, facial pain, or pressure.
  4. Common cold: Common cold is an acute viral infection of the upper respiratory tract. It usually affects the nose, sinuses, larynx, and pharynx, causing symptoms such as cough, sore throat, runny nose, malaise, headache, mild fever, and sneezing (Solo-Josephson, 2017). It is usually transmitted by direct or indirect contact with the cold virus into the eyes or nose; symptoms usually appear within two to three days after exposure to the virus (CDC, 2019a). It is usually self-limiting in generally healthy people, clearing up after 7-10 days (CDC, 2019a). It is often diagnosed using symptoms and history. The common cold is unlikely for this scenario due to the absence of sore throat, headache, malaise, and fever.
  5. Tonsillopharyngitis. Tonsillopharyngitis is an acute inflammation of the tonsils, pharynx, or both. It may also be caused by bacteria. It is transmitted through direct or indirect contact with the secretions of an infected person (Marvin, 2016). Symptoms include rhinorrhea, cough, sore throat, diarrhea, and conjunctivitis (Marvin, 2016). Symptoms usually start about two to seven days after exposure. There is often fever in bacterial tonsillopharyngitis; there may be no fever in viral tonsillopharyngitis. Although some of these symptoms are present in Mr. Brown, the absence of enlarged tonsils and sore throat makes this diagnosis less likely.

 

References

American College of Allergy, Asthma & Immunology (2015). Allergic rhinitis. Retrieved from https://acaai.org/allergies/types/hay-fever-rhinitis

Alam, R. (2020). Allergic Rhinitis (Hay Fever): Diagnosis. Retrieved from   https://www.nationaljewish.org/conditions/allergic-rhinitis-hay-fever/diagnosis

Arbefeville, S., Nelson, K., Thonen-Kerr, E., & Ferrieri, P. (2018). Prospective postimplementation study of Solana group A streptococcal nucleic acid amplification test vs conventional throat culture. American journal of clinical pathology, 150(4), 333-337.

Centers for Disease Prevention and Control (2019). Common colds: Protect yourself and others. Retrieved from  https://www.cdc.gov/features/rhinoviruses/index.html

CDC (2019). Sinus Infection (Sinusitis). Retrieved from  https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sinus-infection.html

Delves, P. J. (2016). Allergic Rhinitis. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/allergic-rhinitis#v651577

Health Quality Ontario (2016). Skin Testing for Allergic Rhinitis: A Health Technology Assessment. Ontario health technology assessment series16(10), 1–45.

Marvin, P. F. (2016). Sore Throat. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-to-the-patient-with-nasal-and-pharyngeal-symptoms/sore-throat

Marvin, P. F. (2017). Sinusitis. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/nose-and-paranasal-sinus-disorders/sinusitis

Nelvis, F. I., Binkley, K., and Kabali, C. (2016). Diagnostic accuracy of skin-prick testing for allergic rhinitis: a systematic review and meta-analysis. Allergy, Asthma & Clinical Immunology 12(20). Retrieved from https://aacijournal.biomedcentral.com/articles/10.1186/s13223-016-0126-0

NHS (2016). Allergic rhinitis: diagnosis. Retrieved from https://www.nhs.uk/conditions/non-allergic-rhinitis/

NHS (2019). Nonallergic rhinitis. Retrieved from https://www.nhs.uk/conditions/non-allergic-rhinitis/

Solo-Josephson, P. (2017). Colds. Retrieved from  https://kidshealth.org/en/parents/cold.html Wheatley, L. M., & Togias, A. (2015). Allergic Rhinitis. The New England Journal of Medicine, 372(5), 456–463. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324099/

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Photo Credit: Getty Images/Blend Images

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.
Excellent Good Fair Poor
Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

·  Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.

45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.
(0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
24 (24%) – 29 (29%)
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.
18 (18%) – 23 (23%)
The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
(0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
(5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
(4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
(3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
(0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
(5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
(4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
(3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
(0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
(5%) – 5 (5%)
Uses correct APA format with no errors.
(4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
(3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
(0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100
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