Posted: December 31st, 2022
Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment
Episodic/Focused SOAP Note Template
Age 50, Sex
Male, Race. Caucasian
CC (chief complaint); nasal congestion and itchy eyes, nose, and palate for five days
HPI: Mr. Brown is a 50-year-old white male presenting with a complaint of nasal congestion, sneezing, rhinorrhea, nasal drainage, itchy nose, eyes, and palate for five days Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment. He states that he has been taking Mucinex for the past two nights with minimal relief. He denies a headache or pain.
Mucinex OTC at bedtime
Hydralazine 25mg TID
-reports seasonal allergies
-denies environmental allergy
PMHx: has a history of hypertension. Denies other illnesses. Immunizations are up to date; he received a flu shot this season. He Received a Tetanus booster last year. Hospitalized in 2018 for left femur fracture repair from a fall. No other significant medical or surgical history Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment
Soc Hx: Mr. Brown lives in a one-story single-family home with his wife and three children. He has his master’s degree in business administration and works in a consulting firm where he has worked for 15 years. He is a former smoker, smoked cigarette from 17-38 years, and marijuana from the age of 18-30. He drinks socially about 1-2 drinks weekly. He states that he does not exercise but takes a walk around the neighborhood about three times weekly. He is a Christian and sometimes attends church on Sundays if he is not too tired. His wife is a beautician who enjoys making healthy meals for the family.
Include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), 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.
-Father has a history of hypertension and BPH
-Mother died at 78 from a stroke.
-Two sisters with no significant medical history
-Three children aged 15, 17, and 20 with no significant medical history.
-Maternal Grandparents died from a car accident when he was 18. He does not remember their ages at death.
-Paternal grandparents are deceased, but he doesn’t remember the ages and cause of death
GENERAL: Alert and oriented to person, place, situation, and time. Denies recent weight changes. Denies fatigue, fever, chills, and weakness.
HEENT: Denies headache. Eyes are itchy and red. No visual loss, blurred vision, double vision or yellow sclerae. States that Ears are itchy, erythematic, and inflamed, denies hearing loss and discharge from the ear. The nose is itchy with sneezing, congestion, and runny nose. Clear nasal discharge. Reports sore throat. Denies difficulty swallowing.
SKIN: No changes in pigmentation. No discoloration, moles, rash, or itching. Denies any other skin abnormalities.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath or cough
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or discomfort. Reports regular daily bowel movements.
GENITOURINARY: Denies burning or pain on urination. Denies urinary tract infection.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain, fatigue, or stiffness.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis. Reports seasonal allergies.
General: Alert and oriented to person, place, situation, and time. Appears well groomed and nourished. Eyes are itchy and red. PERRLA
V/S: Temp: 97.9 degrees Fahrenheit, Pulse:72 beats per minute and regular. Resp:18 beats per minute, Blood Pressure: 141/76, weight: 185 pounds Height: 68 inches
HEENT: Head is normocephalic. Eyes are itchy and red, with no discharge noted in eyes. No vision changes. Ears are red and inflamed. Nasal mucosa is pale and edematous with enlarged nasal turbinate. Clear thin secretions noted in nasal cavities. The throat is mildly erythematous, with no purulent discharge or bleeding noted. Tonsils are symmetrical and pink, no swelling noted.
NECK: Trachea in the midline, no deviation noted. No swollen Lymph nodes noted.
CARDIOVASCULAR: No palpitations or edema. Bilateral radial and dorsalis pedis pulse 2+ and regular.
RESPIRATORY: No shortness of breath, cough, or sputum noted. Lung sounds are clear anteriorly, posteriorly, and laterally. Respirations are even and unlabored.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
American College of Allergy, Asthma & Immunology (2015). Allergic rhinitis. Retrieved from https://acaai.org/allergies/types/hay-fever-rhinitis
Alam, R. (2020). Allergic Rhinitis (Hay Fever): Diagnosis. Retrieved from https://www.nationaljewish.org/conditions/allergic-rhinitis-hay-fever/diagnosis
Arbefeville, S., Nelson, K., Thonen-Kerr, E., & Ferrieri, P. (2018). Prospective postimplementation study of Solana group A streptococcal nucleic acid amplification test vs conventional throat culture. American journal of clinical pathology, 150(4), 333-337.
Centers for Disease Prevention and Control (2019). Common colds: Protect yourself and others. Retrieved from https://www.cdc.gov/features/rhinoviruses/index.html
CDC (2019). Sinus Infection (Sinusitis). Retrieved from https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sinus-infection.html
Delves, P. J. (2016). Allergic Rhinitis. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/allergic-rhinitis#v651577
Health Quality Ontario (2016). Skin Testing for Allergic Rhinitis: A Health Technology Assessment. Ontario health technology assessment series, 16(10), 1–45. Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment
Marvin, P. F. (2016). Sore Throat. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-to-the-patient-with-nasal-and-pharyngeal-symptoms/sore-throat
Marvin, P. F. (2017). Sinusitis. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/nose-and-paranasal-sinus-disorders/sinusitis
Nelvis, F. I., Binkley, K., and Kabali, C. (2016). Diagnostic accuracy of skin-prick testing for allergic rhinitis: a systematic review and meta-analysis. Allergy, Asthma & Clinical Immunology 12(20). Retrieved from https://aacijournal.biomedcentral.com/articles/10.1186/s13223-016-0126-0
NHS (2016). Allergic rhinitis: diagnosis. Retrieved from https://www.nhs.uk/conditions/non-allergic-rhinitis/
NHS (2019). Nonallergic rhinitis. Retrieved from https://www.nhs.uk/conditions/non-allergic-rhinitis/
Solo-Josephson, P. (2017). Colds. Retrieved from https://kidshealth.org/en/parents/cold.html Wheatley, L. M., & Togias, A. (2015). Allergic Rhinitis. The New England Journal of Medicine, 372(5), 456–463. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324099/
Photo Credit: Getty Images/Blend Images
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 Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment. 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.
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.
With regard to the case study you were assigned:
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. Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment
Submit your Assignment.
To submit your completed Assignment for review and grading, do the following:
|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.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
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.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment
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.
|Total Points: 100|
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