Case Study Of Patient Complaining Of Nasal Congestion
Case Study Of Patient Complaining Of Nasal Congestion
Patient information
Patient initials: R.J Age: 50 Race: Hispanic Gender: male
S.
CC:” Nasal congestion, sneezing, rhinorrhea and post-nasal drainage.”
HPI: R.J, a 50-year-old Hispanic man, came to the clinic complaining of nasal congestion, rhinorrhea, sneezing, and post-nasal discharge. He also mentioned experiencing a 5-day itchiness in his nose, eyes, and ears. The patient indicated that his symptoms were getting worse at night and interfering with his sleep. He stated that he had used Mucinex for the last two nights to relieve his symptoms, but that the improvement had been modest. Denies having a headache, nausea, or vomiting. Case Study Of Patient Complaining Of Nasal Congestion
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Medication: Mucinex 600mg 2 tabs PO to reduce chest congestion.
Allergies: Reported seasonal allergies
PMHX: None reported
Past surgical history: none reported.
Family history: No significant family history reported.
Social history: R.J, a 50-year-old Hispanic patient, works as a full-time accountant in a local company. He is married with three children. The patient denies smoking but admits to consuming alcohol on occasion. Exercised twice a week. He is stable financially, and his health is covered. He stated that he wore a seat belt while driving. Case Study Of Patient Complaining Of Nasal Congestion
ROS
General: No fevers, chills, but significant weight gain reported.
HEENT: Denies loss of hearing, and sinusitis. Reported red and itchy eye, nasal congestion, rhinorrhea, and post nasal drainage.
Cardiovascular: Denies chest pain, irregular heartbeats
Respiratory: Denies SOB, and dyspnea on exertion.
GI: Denies vomiting, or diarrhea.
GU: Denies nocturia and urine frequency.
Msk: No myalgias or arthralgias.
Neurologic: Denies chronic headaches.
Psychiatric: Denies depression or anxiety.
Endocrine: Denies heat or cold intolerances
Skin/lymph/heme: No rashes and bruits reported.
O.
PE
VTS: BP 131/66 left arm, sitting using regular adult cuff. Wt.: 201lb Ht.: 5’6 T.: 36.1 RR: 20 P: 78 Sp02: 98%
General: A&Ox3
HEENT; normocephalic. Eyes are reddish and itchy. Nasal mucosa is pale and boggy with clear thin secretion and an enlarged nasal turbinate. No abnormality noted on his tonsil. Throat is erythematous. Case Study Of Patient Complaining Of Nasal Congestion
Cardiovascular: RRR, no murmur, SI and S2 are both normal
Lungs: Clear to auscultation
Skin: Warm and dry. Normal texture
Abdomen: Symmetrical without distention. Bowel sounds are normoactive
MSK: ROM intact. Normal gait and posture.
Neuro: Cranial nerve intact.
Psychiatric: He is oriented to place and time, no abnormal affect noted.
Assessment:
Lab test and result
Skin test: positive for pollen grain.
Diagnosis
Differential diagnosis
Allergic Rhinitis:
Allergic rhinitis is a nose and airway condition. Sneezing, itching, and a runny nose are symptoms (Iordache et al.,2022). Usually caused by an allergic response to pollen grains, dust, or dander in the surroundings. Based on primary complaints and skin test findings, this is the most likely diagnosis.
Non-allergic rhinitis
No-allergic rhinitis is characterized by nasal congestion in the absence of an allergic response. It is distinguished by sneezing, congestion, a runny nose, and an itchy nose. Non-allergic rhinitis, in contrast to allergic rhinitis caused by exposure to allergens such as pollen (Meng et al.,2021)Case Study Of Patient Complaining Of Nasal Congestion, non-allergic rhinitis results from the use of certain drugs and environmental contaminants.
Common cold
The common cold is a highly infectious viral illness of the upper respiratory tract that affects millions of individuals each year (Thomas et al.,2018). It is characterized by a runny nose, sneezing, and nasal congestion. It also manifests as a cough, which was not reported by the client.
Primary diagnoses: Based on the clinical history and test results, allergic rhinitis is the most likely diagnosis.
References
Iordache, A., Boruga, M., Mușat, O., Jipa, D. A., Tătaru, C. P., & Mușat, G. C. (2022). Relationship between allergic rhinitis and allergic conjunctivitis (allergic rhinoconjunctivitis)-review. Romanian Journal of Ophthalmology, 66(1), 8.
Thomas, M., & Bomar, P. A. (2018). Upper respiratory tract infection.
Meng, Y., Wang, C., & Zhang, L. (2021). Diagnosis and treatment of non-allergic rhinitis: focus on immunologic mechanisms. Expert Review of Clinical Immunology, 17(1), 51-62.
• 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. Case Study Of Patient Complaining Of Nasal Congestion
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
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Case study:
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 Case Study Of Patient Complaining Of Nasal Congestion