NUR6512 WEEK 5 ASSESSMENT SOAP NOTE
NUR6512 WEEK 5 ASSESSMENT SOAP NOTE
NUR6512 – Advanced Health Assessment and Diagnostic Reasoning
Patient Initials: LW Age: 20 Gender: Female
Case Study 2
SUBJECTIVE DATA:
Chief Complaint (CC): Patient states that she has heard of flu-like symptoms being present across the college campus. Patient complains of having no appetite and having so sore throat.
This has been happening for the past three days.
History of present illness: Lily Weaver is 20 years old. She is well nourished, appropriately groomed white Caucasian female with well-maintained hygiene came to the clinic today strong headache, painful swallowing, nasal discharge, significantly reduced appetite. Patient denies any symptoms of nausea, vomiting, fever and any other distress. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE
She has expressed that she is concerned based on things that she has heard regarding cases of the flu being diagnosed across the campus. It is noted that patient’s voice sounds strained and hoarse while answering questions. Patient states that she has been taking Tylenol for symptoms and using Cepacol lozenges for throat pain.
Medications:
Tylenol 200mg q.6.h.
Ortho Tri-Cyclin 0.180mg q.h.s.
Cepacol for the sore throat 4 times a day
Allergies: NKA
Past Medical History (PMH):
Measles -at the age of 7
Chicken pox – at the age of 5
Past Surgical History (PSH):
Appendectomy – Age 12 (2008)
Sexual/Reproductive History:
Patient denies any prior diagnosis of STD’s. She is in an active heterosexual relationship with regular intercourse. Patient protects against pregnancy using birth control and requires her long-term boyfriend to use condom. Last menstrual cycle based on patients’ calendar was 9/15/2020.
Personal/Social History:
Patient is active, social college student. She actively participates in several clubs, and volunteers on campus. She states that she drinks occasionally, maybe 1-2 times a month at parties. Patient denies any usage of the illicit drugs in the past and in present time. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE
Immunization History:
Immunizations up to date as per record.
Vaccinations for TD is last received in January 2019.
Annual vaccination for influenza received at September 2020.
Family Medical History:
Hypertension – maternal grandparents, mother
Diabetes – father, and paternal mother
Denies any other significant family history related to health concerns.
Review of Systems:
General: Lily is pleasant, well groomed, able to communicate clearly, and has provided through personal and family medical history. She is cooperative with examination process.
NUR6512 WEEK 5 ASSESSMENT SOAP NOTE HEENT: As per assessment, there are no signs of headache, eye pain, blurry vision, visual changes or the discharge, no sinus pressure, sneezing or runny nose. No mouth or tooth pain, no difficulty swallowing. No ear pain or discharge. No dandruff or scalp lesions. No redness or other inflammatory or traumatic signs. Recent onset of rhinorrhea (3 days ago). Redness noted on the back of the throat. Tonsils are have the signs of inflammation appears to infected and swollen. Patient denies coughing. Hoarseness noted during conversations as well as persistent clearing of throat. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE
Breasts: Equal bilaterally, no signs and symptoms of the discharge, nodules or asymmetry are noted.
Respiratory: Patient not in acute obvious distress, no unlabored breating pattern noted, symmetrical chest, equally and evenly raising during respirations. Fremitus normal. Breath sounds clear and unlabored bilaterally in all fields. Tympanic resonance to percussion anterior and posterior chest assessed no dullness noted.
Cardiovascular/Peripheral Vascular: Negative for chest pain, edema, palpitations, murmurs, or syncope.
Gastrointestinal: Patient denies nausea and vomiting. Does report decreased appetite with onset of sore throat. Bowel patterns are daily and regular. Denies any symptoms of constipation or diarrhea.
Lymphatics: Palpation of the cervical lymph nodes revealed mild inflammatory symptoms as swelling and tenderness. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE
OBJECTIVE DATA:
Physical Exam:
Vital signs: 11 BP 124/78 (right arm, small cuff, sitting) | Pulse 68 | Temp 99.6F (Oral) | Resp 18 (non-labored) | Ht 5’3”. | Wt 126 lb) | BMI 19 kg/m2.
General: Patient is Alert , oriented to person time place and situation. She is the good reliable historian. Patient offers all information freely and without contradiction. Speech coherent free clear and understandable. Speaking using full sentences. She appears well mannered, well-nourished and maintains eye contact throughout the interview. No distress noted.
ASSESSMENT:
Laboratory tests performed:
Comprehensive metabolic panel, complete blood count, rapid streptococcus test, influenza test.
Results:
CMP-Normal
BMP-Normal
Rapid streptococcus test-positive
Influenza test-
Differential Diagnosis:
1) Streptococcal Pharyngitis – Symptoms presented by patient are often associated with Streptococcal Pharyngitis. 7 Typically causes fever, generalized malaise, painful swallowing, and cervical lymphadenopathy. 8 Diagnosis of Streptococcal Pharyngitis based on physical exam, and patient history are insufficient alone. Diagnosis can be confirmed by rapid strep test or throat culture (Gottlieb, Long, Koyfman, 2018).
2) Influenza – This diagnosis should be considered based on patient data, and current outbreaks diagnosed on college campus. 3 Symptoms of influenza include cough, fever, headache, malaise, and sore throat (Ball, et al, 2015). Patient has multiple symptoms matching this diagnosis. While patient has been vaccinated for flu, it should be noted that this is not always effective, and flu diagnosis is still possible. Diagnosis can be confirmed with the use of “Rapid Influenza Diagnostic Test”. Results can be determined in 15-20 minutes (Antonio, et al, 2018 NUR6512 WEEK 5 ASSESSMENT SOAP NOTE).
4) Sinusitis – Sinusitis is a bacterial infection caused by inflammation in nasal passages, allergies, or structural defects. This may cause drainage from the sinus cavities. Symptoms often include headache, facial pressure, nasal discharge, or nasal congestion, and fevers (Ball et al, 2015 NUR6512 WEEK 5 ASSESSMENT SOAP NOTE).
9 5) Diphtheria – Symptoms are noted as sore throat, fever, tender cervical lymph nodes. 5 This condition destroys healthy tissues contained with the respiratory system and can cause thickening, gray coating within the nose and throat referred to as pseudomembrane (Centers for Disease Control and Prevention, 2016).
NUR6512 WEEK 5 ASSESSMENT SOAP NOTE References
Antoniol, S., Fidouh, N., Ghazali, A., Ichou, H., Bouzid, D., Kenway, P.,. Casalino, E. (2018). Diagnostic performances of the Xpert® Flu PCR test and the OSOM® immunochromatographic rapid test for influenza A and B virus among adult patients in the Emergency Department. Journal of Clinical Virology, 99–100, 5–9. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jcv.2017.12.005
Ball, J. 1 W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s guide to physical examination (8th Edition). St. Louis, MO: Elsevier Mosby.
Centers for Disease Control and Prevention [CDC], (2016). Diphtheria. Retrieved from: https://www.cdc.gov/diphtheria/about/symptoms.html
Gottlieb, M., Long, B., & Koyfman, A. (2018). Clinical Mimics: 8 An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. JOURNAL OF EMERGENCY MEDICINE, 54(5), 619–629. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jemermed.2018.01.031
Pendleton, H., Ahlner-Elmqvist, M., Jannert, M., & Ohlsson, B. (2013). Posterior laryngitis: a study of persisting symptoms and health-related quality of life. European Archives of Oto-Rhino-Laryngology: Official Journal of The European Federation of Oto-Rhino-Laryngological Societies (EUFOS): Affiliated with The German Society for Oto-Rhino-Laryngology – Head and Neck Surgery, 270(1), 187–195. https://doi-org.ezp.waldenulibrary.org/10.1007/s00405-012-2116-2
NUR6512 WEEK 5 ASSESSMENT SOAP NOTE – Assessing The Head, Eyes, Ears, Nose, And Throat Example
The Case Study
The patient is a 28-year-old woman who has been experiencing a runny nose and itchy eyes for about nine days. These symptoms typically last for six to eight weeks and occur every spring. Besides the runny nose, she reports having itchy eyes that she feels the urge to scratch, a tickling sensation in her throat, and a feeling of fullness in her ears that sometimes causes them to pop. Last year, she took Claritin with relief. Upon examination, the patient is alert and oriented and has pale nasal mucosa with clear thin secretions and enlarged nasal turbinates that obstruct airway flow, but her lungs are clear. Her tonsils are not enlarged, but her throat is mildly red.
Diagnostic Tests Justification
Based on the patient’s symptoms of a runny nose, itchy eyes, and ears that feel full, a few possible diagnostic tests that could be appropriate for this case are listed and justified below.
- Allergy testing: The patient’s symptoms of a runny nose, itchy eyes, and ears that feel full are consistent with allergic rhinitis, which is an allergic reaction to environmental allergens such as pollen, mold, or pet dander (McCance & Huether, 2019). Allergy testing can help confirm whether the patient has an allergy and identify the specific allergens causing the patient’s symptoms.
- Nasal endoscopy: A nasal endoscopy involves inserting a thin, flexible tube with a camera into the patient’s nose to visualize the inside of the nasal passages and sinuses. This test can help identify any structural abnormalities or inflammation in the nasal passages that may contribute to the patient’s symptoms.
- Sinus imaging: Sinus imaging tests such as CT scans or MRIs provide detailed images of the patient’s sinuses and help identify any blockages or infections that may be causing the patient’s symptoms.
- Throat culture: A throat culture involves taking a sample of the patient’s throat secretions and growing them in a laboratory to identify any bacterial or viral infections that may be causing the patient’s symptoms.
- Complete blood count (CBC): A CBC would give a depiction of the white blood cells and their differentials and show whether there is an excess of or any deficiency of the cells. Elevated eosinophils upon doing a CBC may be suggestive of an allergic condition.
Differential Diagnoses
Based on the patient’s symptoms and the diagnostic tests described above, the following five conditions should be considered in the differential diagnosis:
- Allergic rhinitis: As mentioned above, the patient’s symptoms of a runny nose, itchy eyes, and ears that feel full are consistent with allergic rhinitis, which is an allergic reaction to environmental allergens (Emeryk et al., 2019). Allergy testing can help confirm this diagnosis.
- Sinusitis: The patient’s symptoms of a runny nose and ears that feel full, as well as the presence of pale, boggy nasal mucosa and enlarged nasal turbinates, suggest the possibility of sinusitis, which is an inflammation of the sinuses (Hammer & McPhee, 2018). A nasal endoscopy or sinus imaging test can help confirm this diagnosis.
- Common cold: The patient’s symptoms of a runny nose, itchy eyes, and a tickle in the throat are consistent with the common cold, a viral infection of the upper respiratory tract. A throat culture can help confirm this diagnosis.
- Influenza: The patient’s symptoms of a runny nose, itchy eyes, and a tickle in the throat are also consistent with influenza, which is a viral infection of the respiratory tract. A throat culture or blood test can help confirm this diagnosis.
- Adenovirus infection: Adenovirus respiratory infection could also manifest as a runny nose, itchy eyes, and a tickle in the throat. A throat culture or blood test can help confirm this diagnosis.
Conclusion
In sum, the patient in this case study is a 28-year-old woman who is experiencing a runny nose and itchy eyes, which occur every spring and last for six to eight weeks. She also has a tickling sensation in her throat, and her ears feel full and sometimes pop. Possible diagnostic tests for her symptoms include allergy testing, nasal endoscopy, sinus imaging, throat culture, and a complete blood count. Differential diagnoses for her condition include allergic rhinitis, sinusitis, the common cold, influenza, and adenovirus infection.
NUR6512 WEEK 5 ASSESSMENT SOAP NOTE References
Emeryk, A., Emeryk-Maksymiuk, J., & Janeczek, K. (2019). New guidelines for the treatment of seasonal allergic rhinitis. Postepy Dermatologii i Alergologii, 36(3), 255–260. https://doi.org/10.5114/ada.2018.75749
Hammer, G. D., & McPhee, S. J. (2018). Pathophysiology of disease: An introduction to clinical medicine 8E (8th ed.). McGraw-Hill Education.
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Mosby.
Also Read: NURS 6521 Final Exam Answers