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Focused SOAP Note For Sneezing And Nasal Congestion

Focused SOAP Note For Sneezing And Nasal Congestion

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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 Focused SOAP Note For Sneezing And Nasal Congestion.

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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 Focused SOAP Note For Sneezing And Nasal Congestion.

By Day 6 of Week 5
Submit your Assignment.

Submission and Grading Information

To Prepare
A/B/C/D/E/F/G/H/I/J/K

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 nas
‘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 have selected:

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? Focused SOAP Note For Sneezing And Nasal Congestion
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
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.

Patient Information:

Initials,    R. S    Age    50 years old    Sex    Male   Race   Africa American

SUBJECTIVE DATA.

CC: “Sneezing and nasal congestion.”

HPI: R. S is a 50-year-old African American male. Upon visiting the clinic, the client complains about sneezing, nasal congestion, rhinorrhea, and postnasal drainage. He also reveals struggling with itching eyes, palate, nose, and ears, which started 5 days ago. He reports Mucinex OTC, which he takes at night to enhance breathing as the relieving factor. However, the client denies any aggravating factors. He does not report any pain.

Current Medications: Mucinex OTC 1200/16 mg orally once daily, which is taken to improve breathing.

Allergies: NKA.

PMH: The client denies any medical condition or surgery.

Soc Hx: No information provided.

Fam Hx: Details not availed.

ROS:

GENERAL:  Denies fever or weakness.

HEENT:

Head: Denies hair texture change.

Eyes: Reports itching eyes. Denies loss of vision.

Ears: Reports itching ears and palate.

Nose: The client reports itching nose, nasal congestion, sneezing postnasal drainage, and, rhinorrhea, and.

Throat: Denies enlarged tonsils.

SKIN:  Denies skin dryness or cracking

CARDIOVASCULAR:  Denies chest discomfort.

RESPIRATORY:  Denies shortness of breath or asthma.

GASTROINTESTINAL:  Denies constipation or diarrhea.

GENITOURINARY: Denies frequent urination.

NEUROLOGICAL:  Denies weakness or dizziness.

MUSCULOSKELETAL:  Denies decline in motion range.

HEMATOLOGIC:  Denies bleeding or bruising.

LYMPHATICS:  Denies swollen nodes.

PSYCHIATRIC:  Denies insomnia or suicidal thoughts.

ENDOCRINOLOGIC:  Denies changes in appetite.

ALLERGIES:  Denies any allergy Focused SOAP Note For Sneezing And Nasal Congestion.

OBJECTIVE DATA.

Physical exam:

General: The client is a 50 years old African American male. He maintains an upright posture and eye contact throughout the interview. The client is well-groomed and presentable. His affect, judgment, and mood are good. He is alert and oriented.

Vital signs: T 98F; B/P-120/69; RR 23 beats per minute; Pulse Ox 98%; W 182lbs;  H 5’9″

SKIN: No cracking or rashes seen.

HEENT: Hair is black and evenly distributed. The eyes are bilateral with accommodation at 3mm. No drainage is present on external auditory canals. The client is seen pressing and rubbing the bridges of his nose. A pale color was seen in the nasal mucosa with thin secretions. Enlargement in nasal turbinates was seen. No swollen tonsils were noted.

Neck: Full range of motion of neck and shoulders was noted.

Chest/Lungs: Clear lungs on auscultation.

Heart/Peripheral Vascular: Normal S1 and S2 present.

Abdomen: No tenderness.

Genital/Rectal: Omitted

PV: Palpable peripheral pulses.

Musculoskeletal: Normal back curvature

Neurological: Motor is 5/5 throughout.

Psych: Good judgment and insight

Diagnostic results:

  1. Lab test for IgE antibodies was ordered: The results indicated the presence of allergen-specific IgE in the serum.
  2. Skin prick test: Awaiting results.

ASSESSMENT.

Differential Diagnoses

  1. Allergic rhinitis (AR)
  2. Non-allergic rhinitis
  • Infectious rhinitis
  1. Nasal polyposis
  2. Nasopharyngeal carcinoma

The original diagnosis for this client is allergic rhinitis, which is a sub-category of chronic rhinitis. People with this condition mainly complain about sinus pressure, nasal congestion, itching in different parts, including the nose, mouth, eyes, or throat, post-nasal drainage, puffy/swollen eyelids, sneezing, rhinorrhea, and cough (Greiwe & Bernstein, 2019). The client has allergic rhinitis since has most of these symptoms such as sneezing, nasal congestion, rhinorrhea, postnasal drainage, and itching eyes, palate, nose, and ears.

Non-allergic rhinitis is the second differential diagnosis for this client. Its symptoms include nasal congestion, chronic sneezing, or a drippy nose (Terada & Kawata, 2022)Focused SOAP Note For Sneezing And Nasal Congestion. Similarly, the client reported nasal congestion, sneezing, rhinorrhea, and postnasal drainage. He also reported itching nose, palate, eyes, and ears, indicating the likelihood of non-allergic rhinitis. Nonetheless, this condition is ruled out due to the absence of a drippy nose, which is a significant symptom of non-allergic rhinitis.

Infectious rhinitis is another potential diagnosis for this client. It is mainly characterized by sneezing, runny, stuffy, and itchy nose. People with this condition also report itching eyes, throat, and ears, nosebleeds, or clear nasal drainage (Liva et al., 2021). The client might have this condition since he reported nasal congestion, sneezing, rhinorrhea, postnasal drainage, and itchy nose, ears, eyes, and throat. However, this infectious rhinitis is ruled out due to the absence of significant symptoms, including nosebleeds, runny nose, and clear nasal drainage.

The client should also be diagnosed with nasal polyposis, which is characterized by a runny nose, persistent stuffiness, postnasal drip, reduced sense of smell, loss of taste, pain in the upper teeth, headache, facial pain or headache, or pressure over the face or forehead (Hopkins, 2019). The client might have this condition since he reported postnasal drip and nasal congestion. However, this condition is ruled out due to the absence of other vital signs such as runny nose, reduced sense of smell, loss of taste, pain in the upper teeth, headache, facial pain or headache, or pressure over the face or forehead.

The last differential diagnosis for this client is nasopharyngeal carcinoma. The most significant symptoms of this condition include a lump in the neck, blood in saliva, bloody nasal discharge, hearing loss, nasal congestion, sore throats, frequent ear infections, or headaches (Chen et al., 2019). The client reported nasal congestion, making this condition a potential diagnosis. However, this disease is ruled out due to the absence of vital symptoms such as a lump in the neck, blood in saliva, bloody nasal discharge, hearing loss, and sore throats Focused SOAP Note For Sneezing And Nasal Congestion.

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References

Chen, Y. P., Chan, A. T., Le, Q. T., Blanchard, P., Sun, Y., & Ma, J. (2019). Nasopharyngeal carcinoma. The Lancet, 394(10192), 64-80. DOI:https://doi.org/10.1016/S0140-6736 (19)30956-0.

Greiwe, J. C., & Bernstein, J. A. (2019). Allergic and mixed rhinitis: diagnosis and natural evolution. Journal of Clinical Medicine, 8(11). Doi: 10.3390/jcm8112019.

Hopkins, C. (2019). Chronic rhinosinusitis with nasal polyps. New England Journal of Medicine, 381(1), 55-63. DOI: 10.1056/NEJMcp1800215

Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/ 10.3390/jcm10143183.

Terada, T., & Kawata, R. (2022). Diagnosis and Treatment of Local Allergic Rhinitis. Pathogens, 11(1), 80. https://doi.org/10.3390/pathogens11010080 Focused SOAP Note For Sneezing And Nasal Congestion