SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat

SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat

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. SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat

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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 SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat.
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.

***Assigned Case Study for assignment:
Focused Nose Exam

A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte 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 SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat.

Patient Information

Name: Charlotte Age: 28 years Sex: Female

Subjective

Chief Complaint: Runny nose, itchy eyes, and ears feel full

History of Present Illness (HPI)

The patient is a 28-year-old female who presented with itchy eyes and runny nose symptoms that started nine days ago. The symptoms are described as clear mucus. The patient rates the intensity of the itchiness as 10/10, claiming that they itch so much that she wishes to remove them. Sometimes, she has a tingly feeling in her throat. The patient experiences these symptoms every spring and took Claritin during the last episode in the previous year, which relieved the symptoms.

Current Medications: None

Past Medical History: The patient experiences itchy eyes, runny nose, and full ears every spring, and the symptoms last about a month and a half to two months.

Family History: Mother has hypertension, and father recently passed away from cardiovascular disease. There are no history of ear, nose, and throat (ENT) conditions within the patient’s immediate family.

SH: The patient is a stay-at-home mom living in a house with smoke detectors. No history of tobacco use, occasional alcohol use, married for two years

Allergies: pollen allergy, no known food allergies

Immunizations: Up to date on immunizations, first covid-19 vaccine 1/23/2021 Pfizer; 2^nd Covid vaccine 2/23/2021 Pfizer

Review of Systems

General; denies fever and chills

Skin: negative for itchiness or rash

HEENT; Eyes: Confirms severe itching and denies vision loss, yellowing, blurred, or double      vision

                 Ears, Nose, and Throat: Confirm running nose and discomfort in the throat and denies congestion, sneezing, and hearing loss.

Respiratory: no cough, sputum, angina, or dyspnea

Neurological examination was negative for headache, ataxia, dizziness, tingly feeling in arms and legs, paralysis, or changes in bladder control SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat.

Genitourinary: Last Monthly Period (LMP): 26^th June 2022, denies pregnancy burning sensation or itching during urination.

Musculoskeletal: negative for joint or muscle pain  or stiffness

Hematological: no history of bleeding or anemia

Lymphatic: negative for inflamed spleen, positive for inflamed lymph nodes at the neck.

Psychiatric: The patient is well dressed, coherent in speech, follows the conversation well, and denies depression or anxiety.

Endocrinological: No history of polyuria or polydipsia, extreme heat or coldness except during the last trimester of her most recent pregnancy.

Cardiovascular: negative for chest pain, palpitations, pressure, edema, or discomfort

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Objective

Physical Examination:

Vital Signs: Blood Pressure (BP) 186/102; Pulse Rate 70 bpm; Respiratory Rate 16; Body Temperature 98.6 Weight 119lbs; Height 5 feet, five inches.

General: The patient appears stressed about the recurring nature of the condition. She rubs her nose and eyes constantly due to the discomfort.

Ears: The ears appear normal. The health professional assesses for eustachian tube blockage through the pneumatic otoscope, as the patient complains of filled ears. The health professional also checks for fluid in the eardrum through the Valsalva maneuver. The technique entails instructing the patient to blow out the nose while applying pressure by holding it shut. The examination confirms fluid-filled ears.

Eyes: Eyelids appear swollen due to rubbing

Nose: The patient tends to breathe with the mouth due to a congested nose. The nose is congested due to excessive mucus production. Upon examination with a speculum, the nasal mucosa appears blue, pale, and swollen. An endoscopic examination found no polyps or other structural deformities (Small et al., 2018)SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat.

Face: The sinuses feel tender upon palpation, and the patient expresses facial discomfort. The face appears elongated due to continuous mouth-breathing.

Throat: posterior drainage of mucus was observed.

Neck: Swollen lymph nodes

Diagnostic Tests

Although the patient history and physical diagnosis point to an allergic rhinitis diagnosis, confirmatory diagnostic tests are required. The health professional suspects that the patient develops an allergic reaction to pollen every spring and orders the skin prick test. The test involves introducing the commercial allergen, in this case, pollen, into the skin’s epidermis by pricking the skin. Within 20 minutes, the patient responded to the prick with a typical allergic reaction characterized by a blanched wheal, redness, heat, and inflammation at the prick site. This test yields immediate results, helpful in ruling out conditions with similar symptoms. The health professionals requested an alternative allergen-specific IgE assay to test the patient reaction to the pollen in vitro.

 

Assessment

Differential Diagnosis

1. Viral Rhinitis

The patient’s symptoms may be confused for viral rhinitis, also known as the common cold. For example, a viral rhinitis patient may present with a runny nose, headaches, irritated throat, itchy eyes, and filled ears. However, this condition has been ruled out because Charlotte denied feeling chills and joint and muscle aches, and her body temperature fell within the normal limits, yet viral rhinitis usually causes low-grade fever (Ohio State University, 2019)SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat. Moreover, the common cold’s chief complaint would be a runny nose and throat irritation, whereas the chief complaint, in this case, was itchy eyes. Further, upon physical examination, the health professional identified a pale blue nasal mucosa instead of red, as would have been the case in viral rhinitis. Finally, viral rhinitis lasts between 1 to 2 weeks while the patient experiences the symptoms between 1,5 and 2 months every year, a description more consistent with allergic rhinitis.

2. Acute Bacterial Rhinosinusitis

The patient’s condition may be misdiagnosed as acute bacterial rhinosinusitis because its clinical presentation is consistent with some symptoms. For example, the patient may experience nasal congestion and tender sinuses upon palpation. However, a professional will rule this condition out because the mucus has a thick consistency and is green or yellow in contrast with the clear runny mucus observed in Charlotte’s case (Ohio State University, 2019)SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat. Further, the patient’s symptoms are not accompanied by fever, muscle ache, and fatigue, and she has not reported the worsening of symptoms over time.

3. Immotile Cilia Syndrome

Patients with conditions endure frequent respiratory infections due to the impaired structure and function of respiratory cilia. These anatomical structures are responsible for moving mucus, dust particle, and microorganisms within the tract, and impaired function is characterized by excessive mucus production, nasal congestion, difficulty in breathing, and ear infections. While these symptoms are similar to the patient’s clinical presentation, the health professional will rule out this condition because it begins in infancy (Ohio State University, 2019)SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat. Moreover, the symptoms may occur at any time of the year, unlike the patient’s description.

4. Adenoid Obstruction

Patients with condition may present with nasal congestion that predisposes them to oral breathing. They also present with eustachian tube blockage (Singh eat al., 2017). This presentation is partially consistent with Charlotte’s description but will be ruled out because the endoscopy found no structural abnormalities. Moreover, the chief complaint in Charlotte’s case is itchy eyes while adenoid obstruction is primarily associated with sleep apnea.

5. Primary/presumptive diagnosis: the primary diagnosis is allergic rhinitis because the history and clinical presentation agree with the disease’s description. The patient presents with filled ears, runny nose, itchy eyes, and throat irritation which lasts for about two months every year and disappears in response to environmental stimuli, confirmed through diagnostic tests to be pollen grains.

 References

Ohio State University. (2019). Allergic Rhinitis. OSU. https://u.osu.edu/allergicrhinitis2019/differential-diagnosis/

Singh, I., Jain, A., Prasad, P., & Rajpurohit, P. (2017). Adenoid Hypertrophy in Adults: An Underdiagnosed Entity?. Archives of Otolaryngology & Rhinology, 3(1), 006-008. https://www.peertechzpublications.com/Otolaryngology-Rhinology/AOR-3-133.php

Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy, asthma & clinical immunology, 14(2), 1-11. https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0280-7 SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male)SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat. You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use)SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat, any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

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A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting SOAP Note For Assessing The Head, Eyes, Ears, Nose, And Throat