NURS- 6512Comprehensive SOAP: Assessing the Head, Eyes, Ears, Nose, and Throat Paper

NURS- 6512Comprehensive SOAP: Assessing the Head, Eyes, Ears, Nose, and Throat Paper

NURS- 6512Comprehensive SOAP: Assessing the Head, Eyes, Ears, Nose, and Throat Paper

SUBJECTIVE DATA:

Chief Complaint (CC): “I have been having itchy nose, eyes, palate, and ears.”

History of Present Illness (HPI): R.B is a 50-year-old A.A male presented with complaints of itchy nose, eyes, palate, and ears. The symptoms began five days, and they occurred abruptly. He states that they are associated with nasal congestion, rhinorrhea, sneezing, and postnasal drainage. He describes the nasal secretions as thin and watery. The symptoms are not exacerbated or associated with any environmental factors or activity. R.B reports having taken OTC Mucinex for the past two nights to aid in 0breathing while sleeping. However, the Mucinex only had a minimal impact in improving nasal congestion.

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Medications: OTC Mucinex to relieve nasal congestion.

Allergies: No food or drug allergies.

Past Medical History (PMH: No history of chronic illnesses.

Past Surgical History (PSH): Laparotomy at 38 years due to Intestinal obstruction.

Sexual/Reproductive History: No history of STIs.

Personal/Social History: He denies a history of tobacco or illicit drug use but reports taking whiskey on his off days. His hobbies include baking and watching food shows. He denies having difficulties carrying out ADLs. The patient goes to the gym at least twice a week. He reports having at least three meals per day.

Immunization History: Immunization is up-to-date. The last Flu shot was ten months ago, and TT was three years ago.

Significant Family History: The mother had Alzheimer’s and hypertension. The father died from renal failure and had Diabetes. The elder sibling has Diabetes. Children are alive and well.

Lifestyle: Richard was born and raised in Irving, TX. He is married and has three living children, 24, 20, and 17 years. He is a chef working in a restaurant in Irving. The patient states that his wife, children, and best friend are his support system.

Review of Systems:

General: Denies weight changes, fatigue, chills, or fever.

HEENT: Head: Denies headache or head trauma. Eyes: Reports itchy eyes and increased tearing. Negative for double/blurred vision or yellow sclera. Ears: Reports itchy ears. Negative for ear discharge, pain, or hearing loss. Nose: Reports itchy nose, sneezing, nasal congestion, rhinorrhea, and postnasal drainage. Denies epistaxis. Throat: Reports itchy palate. Negative for sore throat, hoarseness, or swallowing difficulties.

Neck: Negative for neck pain or stiffness.

Breasts: Denies breast pain.

Respiratory: Denies chest pain/discomfort, cough, sputum production, or shortness of breath.

Cardiovascular/Peripheral Vascular: Denies edema, chest pain/pressure, palpitations, or dyspnea on exertion.

Gastrointestinal: Denies nausea/vomiting, epigastric pain, abdominal pain, flatulence, or rectal bleeding.

Genitourinary: Negative for urinary symptoms or penile discharge.

Musculoskeletal: Denies muscle pain, joint pain, or difficulties in movement.

Psychiatric: Denies anxiety or depressive symptoms.

Neurological: Denies fatigue, dizziness, loss of consciousness, muscle weakness, or tingling sensations.

Skin: Negative for skin-color changes, rashes, itchiness, or bruises.

Hematologic: Denies bruising or bleeding.

Endocrine: Denies excessive sweating, urination, hunger, or thirst, or heat/cold intolerance.

Allergic/Immunologic: Denies hives, asthma, or allergic infections.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP- 132/80, HR- 92, RR-20, Temp-98.42F

HT- 5’5, Wt- 167 pounds.

 General: Male patient in his 50s with no acute distress. The patient is alert and oriented. He is neat and appropriately dressed. He maintains adequate eye contact, uses positive facial expressions, and has clear and goal-directed speech. Normal gait and posture.

HEENT: Head: Symmetrical and atraumatic. Eyes: Watery and red eyes; Dark circles around the eyes; the conjunctivae is injected and swollen with excessive lacrimation; PERRLA. Ears: No ear discharge, Abnormal flexibility of the tympanic membrane; Mastoid bone is non-tender. Nose: The nasal mucosa is pale and boggy with clear thin secretions and enlarged nasal turbinates. Throat: Throat clearing; the throat has mild erythematous; Tonsils are non-enlarged.

Neck: The neck is symmetrical. Lymph nodes are non-palpable. The Thyroid gland is normal on palpation.

Chest/Lungs: Smooth and even respirations. Chest rises and falls in unison on respirations. Lungs are clear on percussion and auscultation.

Heart/Peripheral Vascular: No edema of lower limbs or distension of neck veins. Heart rate and rhythm are regular. S1 and S2 are present. No S gallop, heart murmurs, or rubs.

Skin: Skin is fair and smooth with turgor and no discoloration.

Diagnostic Tests

1. Diagnostic tests that would be ordered to help in making a diagnosis include:

Complete blood count (CBC): A CBC will help establish the presence of infection through the white blood cell count and the presence of an allergic based on the number of eosinophils (Leader & Geiger, 2021).

1. Allergy skin tests: The results will help establish if the patient has an allergy to a specific allergen (Leader & Geiger, 2021).

ASSESSMENT:

Vasomotor Rhinitis

Vasomotor rhinitis is a syndrome characterized by rhinorrhea and nasal congestion unrelated to a particular allergen. Common symptoms include headache, postnasal drip, nasal congestion, rhinorrhea, facial pressure, sneezing, throat clearing, and low-grade fever (Yıldız, 2020). Physical exam findings include boggy edematous mucosa with clear nasal secretions. Besides, mucosal injection and lymphoid hyperplasia involving the adenoids, tonsils, and lingual tonsils can occur (Leader & Geiger, 2021). Vasomotor rhinitis is a differential diagnosis based on positive findings of nasal congestion, rhinorrhea, sneezing, postnasal drainage, throat clearing, injected conjunctivae, and pale boggy nasal mucosa.

Allergic Rhinitis

Rhinitis is characterized by an inflammation of the nasal mucous membrane. The inflammation results in rhinorrhea, nasal congestion, and various associated symptoms based on etiology, including sneezing, itching, watery or purulent rhinorrhea, and loss of smell (Yıldız, 2020). Allergic rhinitis is a differential diagnosis based on the positive symptoms of itchy nose, eyes, palate, and ears, sneezing, rhinorrhea, nasal congestion, and postnasal drainage. Besides, he has physical findings consistent with Allergic rhinitis, including clear thin secretions, a nasal mucosa that is pale and boggy, enlarged nasal turbinates, excessive tearing, and dark circles around the eyes.

Common Cold

Clinical features of the common cold include nasal dryness, nasal irritation, sore throat, dripping clear nasal discharge with congestion, and sneezing. Other features include cough, headache, loss of sense of taste and smell, facial and ear pressure, voice hoarseness, and low-grade fever (Jaume et al., 2020). The patient’s symptoms consistent with Common cold include clear thin secretions, rhinorrhea, postnasal discharge, nasal congestion, sneezing, and throat clearing.

Acute Sinusitis

Acute sinusitis is characterized by pain or pressure over the cheek. The pain exacerbates by bending down or straining. Clinical features include facial pain, postnasal discharge, nasal blockage, persistent cough, reduced sense of smell, and pharyngeal irritation (Wyler & Mallon, 2019). Acute sinusitis is a differential diagnosis based on positive symptoms of nasal congestion, postnasal drainage, nasal blockage, and throat clearing. Nonetheless, the patient has no facial pain/pressure or tenderness in the sinuses, which are key features of sinusitis. This rules out acute sinusitis as the primary diagnosis.

Influenza

Clinical features of Influenza include nasal discharge, cough, red, watery eyes, fever, sore throat, myalgia, tachycardia, frontal or retro-orbital headache, body weakness, and fatigue (Gaitonde et al., 2019). Influenza is a differential diagnosis based on the patient’s findings of nasal discharge, red, watery eyes, and excessive tearing.

References

Gaitonde, D. Y., Moore, F. C., & Morgan, M. K. (2019). Influenza: Diagnosis and treatment. American family physician, 100(12), 751-758.

Jaume, F., Valls-Mateus, M., & Mullol, J. (2020). Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020. Current Allergy and asthma reports, 20(7), 28. https://doi.org/10.1007/s11882-020-00917-5

Leader, P., & Geiger, Z. (2021). Vasomotor rhinitis. StatPearls [Internet].

Wyler, B., & Mallon, W. K. (2019). Sinusitis update. Emergency Medicine Clinics, 37(1), 41-54. https://doi.org/10.1016/j.emc.2018.09.007

Yıldız, E. (2020). Non-Allergic Rhinitis. In Rhinitis. IntechOpen. DOI: 10.5772/intechopen.94544

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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.
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.
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
The 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.
Focused assessment means you still fill out all review of systems and as needed type “Patient denies” in the sections that you are not covering or are needed. Again, you are allowed to make up the information that is needed to fill out the episodic note.
With regard to the case study you were assigned:
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.

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.
NURS_6512_Week_5_Assignment_1_Rubric
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.
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.
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 (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.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
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 (5%)
Uses correct APA format with no errors.