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

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

 Episodic/Focused SOAP Note Template

Patient Information:

Initials: L.M                Age: 20 years old                    Sex: Female                 Race: Caucasian

S.

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.

Location: Throat

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.

ROS:

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

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 O.

Physical exam:

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.

A.

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.

References

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. https://doi.org/10.1111/ans.14787

Chow, E. J., Doyle, J. D., & Uyeki, T. M. (2019). Influenza virus-related critical illness: prevention, diagnosis, treatment. Critical care, 23(1), 1-11. https://doi.org/10.1186/s13054-019-2491-9

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: PMC7145142

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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.–
Levels of Achievement:
Excellent 45 (45.00%) – 50 (50.00%)
Good 39 (39.00%) – 44 (44.00%)
Fair 33 (33.00%) – 38 (38.00%)
Poor 0 (0.00%) – 32 (32.00%)
• List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.–
Levels of Achievement:
Excellent 30 (30.00%) – 35 (35.00%)
Good 24 (24.00%) – 29 (29.00%)
Fair 18 (18.00%) – 23 (23.00%)
Poor 0 (0.00%) – 17 (17.00%)
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.–
Levels of Achievement:
Excellent 5 (5.00%) – 5 (5.00%)
Good 4 (4.00%) – 4 (4.00%)
Fair 3 (3.00%) – 3 (3.00%)
Poor 0 (0.00%) – 2 (2.00%)
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–
Levels of Achievement:
Excellent 5 (5.00%) – 5 (5.00%)
Good 4 (4.00%) – 4 (4.00%)
Fair 3 (3.00%) – 3 (3.00%)
Poor 0 (0.00%) – 2 (2.00%)
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.–
Levels of Achievement:
Excellent 5 (5.00%) – 5 (5.00%)
Good 4 (4.00%) – 4 (4.00%)
Fair 3 (3.00%) – 3 (3.00%)
Poor 0 (0.00%) – 2 (2.00%)