Episodic/Focused SOAP Note: Focused Nose Exam

Episodic/Focused SOAP Note: Focused Nose Exam – 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…

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Episodic/Focused SOAP Note: Focused Nose Exam

Instructions

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.

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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.

CASE STUDY 1: Focused Nose Exam

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.

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Solution

Episodic/Focused SOAP Note

Patient Information:

• R, 50, Male, Race

Subjective

• CC: “Nasal Congestion” and “5-day itching nose”
• HPI: Richard is a 50-year-old male complaining of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. The patient’s nose, eyes, palate and ears have been itchy for the past five daya. He is alert and oriented x 3. The patient is taking Mucinex OTC to aid breathing with less significant effects. Besides, the patient has no headache or pain. The patient’s ears and throat are red and inflamed. The patient is pale, has watery nasal mucosa with thin and clear secretions. Turbinates are enlarged.
• Current Medications: Mucinex OTC 1 tab orally every night.
• Allergies: NKDA
• PMHx: Hypertension
• Soc Hx: Married, three children aged 25, 21 and 17. Occasionally drink alcohol. Nonsmoker. Routine exercise and healthy diet.
• Fam Hx: Parents diseased. Wife and children are all alive and healthy.

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Reviews of Systems:

• GENERAL:  Well dressed, No fever, chills or fatigue. Alert and oriented x3.
• HEENT: No headaches. Itchy and red eyes. PERRLA, vision is intact. Hearing intact, red and inflamed throat, pale and watery nasal mucosa with thin secretions. Tonsils normal. Throats appear erythematous.
• Neck: Trachea is well positioned Lymph node not swollen.
• Skin: No itchy or skin rash. Skin color intact. Normal skin turgor.
• CARDIOVASCULAR:  No pain in the chest area. No chest pressure or discomfort. No edema of palpitations.
• RESPIRATORY:  No cough, dyspnea, or phlegm.
• GASTROINTESTINAL:  No nausea, anorexia, constipation, vomiting or diarrhea. No heartburn or abdominal pain.
• NEUROLOGICAL:  Itchy and red eyes. Sense of smell, hearing and taste intact. No headache or dizziness.
• MUSCULOSKELETAL:  No joint, back or muscle pain/stiffness. Denies muscle weakness.
• LYMPHATICS: Normal nodes.
• PSYCHIATRIC:  No history of psychological disorder.
• ENDOCRINOLOGIC: No frequent urination or polydipsia.
• ALLERGIES:  Seasonal allergies. NKDA.

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Objective

• General: AAO x 4, denies weakness, denies fatigue, well groomed, well nourished.
• V/S: Temp: 99F, P: 72, R: 15, BP: 123/79, Wt: 185 lbs, Ht: 5”9”
• HEENT: No headaches. Itchy and red eyes. PERRLA, vision is intact. Hearing intact, red and inflamed throat, pale and watery nasal mucosa with thin secretions. Tonsils normal. Throats appear erythematous.
• C/V: No pain in the chest area. No chest pressure or discomfort. No edema of palpitations.
• Extremities: Normal breathing, Joints are symmetrical. Regular pulse and heartbeat.
• Skin: Non itchy, no rashes, good turgor, rough, dry, and yellowing skin.
• Respiratory:  No cough, dyspnea, or phlegm.
• Musculoskeletal:  No joint, back or muscle pain/stiffness. Denies muscle weakness.
• Lymphatics: Normal nodes.
• Allergies:  Seasonal allergies. NKDA.

Diagnostic results:

• Skin Test: positive to pollen.
• Skin tests are done to diagnose seasonal reactions to pollen (Delves, 2016).
• Allergen-specific IgE antibody testing: Not done.
• Use to identify if a medication is causing allergic reactions (Quillen & Feller, 2006)

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Assessment.

Differential Diagnoses:

• Allergic rhinitis: Symptoms include sneezing, obstruction of the airflow, inflammation reaction and nasal congestion (Delves, 2016). Other symptoms include itchy nose, eyes or skin throat irritation, cough and fatigue.
• Rhizovirus: Viral infection of the respiratory tract. Symptoms include sore throat, facial pressure, cough and loss of smell/taste (Ball et al., 2015). A patient can also suffer swollen eyes causing headaches.
• Sinusitis: Symptoms include obstruction of the nasal cavity, congestion rhinorrhea, facial pressure/pain and headache (Marvin, 2017). A patient can also loos sense of smell or taste, fatigue or anterior discharge.
• Sore throat: Painful posterior pharynx during swallowing. Symptoms include enlarged tonsils, and painful posterior pharynx (Marvin, 2016). A patient can also have pus from the tonsils, or scratchy throat sensation.
• Acute sinusitis: Caused by bacterial infection and symptoms include nasal discharge with pus and loss of sense of smell (Petersen, 2016). Also, the patient can have a nasal blockage or drip.

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References

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s Guide to Physical Examination-E-Book. Elsevier Health Sciences.
• 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#v6515770
• Marvin, P. F. (2016). Sore Throat. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-tothe-patient-with-nasal-and-pharyngeal-symptoms/sore-throat
• Petersen, S. W. (2016). Advanced health assessment and diagnostic reasoning. Jones & Bartlett Learning.
• Quillen, D. M., & Feller, D. B. (2006). Diagnosing Rhinitis: Allergic vs. Nonallergic. American Family Physician, 73(9), 1583-1590. Retrieved from https://www.aafp.org/afp/2006/0501/p1583.html

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