NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat Soap Note

NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat Soap Note

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Richard is a 50-year-old, white, male that presents to the clinic complaining of nasal congestion, rhinorrhea, and postnasal drainage. Over the past five days his nose, eyes, throat, and ears have been itchy. He has been taking Mucinex OTC the past two nights to help him breathe while he sleeps. The purpose of this paper is to create a focused SOAP note, provide possible conditions and diagnoses for the patient above and rationale.

NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat Soap Note

Episodic/Focused SOAP Note Template

Patient Information:

Patient Initials: R.B.               Age: 50                                   Gender: Male                Race: White

Subjective Data:

CC: Nasal congestion, sneezing, runny nose, itchy nose, eyes, and throat over the past 5 days.

HPI: 50-year-old white male presents to clinic with a runny nose, sneezing, and itchy nose, eyes and throat. Patient states he has been experiencing symptoms over the past 5 days. Patient reports feeling like the back of his throat is itching and pressure under his eyes and above his cheeks on both sides. He states it’s been difficult for him to breathe at night, and has been taking Mucinex OTC x2 days to help him sleep with little to no relief. He rates his pain 4/10 to his forehead and sides of nose which feels like dull pressure.

Current Medications:

  • Mucinex 600mg PO q12H PRN
  • Acetaminophen 650mg PO Q4H PRN pain
  • Lisinopril 10mg PO daily

Allergies:

  • Cats: itching and sneezing
  • Pollen: itching watering eyes, sneezing

Past Medical History (PMH):

  • HTN
  • Hyperlipidemia
  • Seasonal allergies

Past Surgical History (PSH):

  • Appendectomy 3/29/2002
  • Bilateral Cataract Removal with IOL implant 6/5/2017

Personal/Social History:

            Alcohol Use: Denies

Caffeine Use: Current

Caffeine Type: Coffee

Caffeine Frequency: Daily

Tobacco/Nicotine Usage: Former, quit smoking in 2002

Recreational Drug Use: Denies

Significant Family History:

Father: HTN, Alcoholism

Mother: Healthy, no PMH

Paternal Grandfather: not living, MI, CAD, HTN, hyperlipidemia

Paternal Grandmother: Dementia, CVA, TIA

Maternal Grandmother: HTN

Maternal Grandfather: unknown

Sister: healthy, no PMH

Immunization History: Immunizations UTD, Tdap 2018, Influenza Vaccine 11/2019

Lifestyle: Patient lives at home with wife; employed at Altec as a machinist; lives just outside of town in a low crime area; financially stable with medical insurance. Walks 3 miles daily and follows a low fat, low carb diet. Patient has a good support system of wife, kids, and grandchildren. Sees his PCP yearly for routine care and PRN.

Review of Systems (ROS):

GENERAL:  No weight loss, fever, chills, light headedness, weakness or fatigue. Complains of dull pressure to his forehead over the past 5 days.

HEENT:   Denies any vision loss or double vision. States he has had cataracts removed bilaterally and sees well following surgery. Experiencing itchy watery eyes, nose, and   throat. Nasal drainage is clear.

SKIN:  No rashes or itching.

CARDIOVASCULAR:  Denies any chest pain or heart palpitations.

RESPIRATORY:  Complains of trouble breathing at night when laying down over the past 4-5 days due to “stopped up nose.”

GASTROINTESTINAL:  Denies any changes in appetite or weight. No constipation or diarrhea.

GENITOURINARY:  Denies any burning or trouble urinating. Denies incontinence or penile discharge.

NEUROLOGICAL:  Complains of dull headache over the last 4-5 days, between his eyes.

MUSCULOSKELETAL:  Denies any joint pain, swelling or tenderness.

LYMPHATICS:  Complains of lymph nodes under his chin being swollen.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies excessive sweating, thirst, or urination.

ALLERGIES:  Denies frequent or re-occuring infections.

Objective Data:

            Physical exam:

Vital signs: BP 138/84, left arm, sitting, regular cuff; manual; P 91 and regular, T 36.7

Orally; RR 18 non-labored; Wt: 179 lbs; Ht: 6’1”; BMI: 23.6

General: A/Ox4 well groomed, dressed appropriately.

HEENT: PERRLA, normal conjunctivae, mucous membranes moist. Erythema noted to auditory canal and tympanic membrane bilaterally. Pale, boggy, nasal mucosa, and enlarged turbinates.

Neck: Supple, no JVD noted, no bruits. Symmetric, no abnormal findings.

Chest/Lungs: Clear to auscultation in all lung fields.

Cardiovascular: Regular rate and rhythm. No murmur, rub, or gallops noted.

Abdomen: BS positive X4 quadrants, non-tender, soft, round, no rebound tenderness or guarding noted.

Musculoskeletal: Well developed, no abnormal findings.

Neurological: A/O x4, calm and cooperative. Mood and affect are appropriate.

Skin: No rashes or abnormal findings.

Diagnostic results:

1.) Throat swab to r/o strep (Stefaniuk, Bosacka, Wanke-Rytt & Hryniewicz, 2017).

2.) Nasal swab to r/o COVID-19 (CDC, 2020.)

3.) Chest x-ray (Demarco, 2020.)

Assessment:

            Primary Diagnosis:

  • Upper Respiratory Infection: Could be bacterial or viral. Symptoms include sore throat, nasal symptoms, and cough (Schroeck, et. al, 2015.)

            Differential Diagnoses (DDx):

  • Sinusitis: Symptoms may include purulent nasal discharge, nasal obstruction, facial pain, pressure and/or fullness (Rosenfeld, 2016.)
  • Common Cold: Upper respiratory symptoms that can be caused by a variety of different pathogens. Symptoms include sore or scratchy throat, nasal obstruction, cough, nasal secretions, swollen and red nasal turbinates (Turner, 2015.)
  • Allergic Rhinitis: Symptoms include sneezing, nasal pruritus, airflow obstruction, and clear nasal discharge. Often caused by allergens like seasonal pollen, mold, dust mites, and pets (Wheatley & Togias, 2015.)
  • COVID-19: Symptoms can include fever, cough, fatigue, sputum production, headache, dyspnea, sore throat, and GI problems such as diarrhea, N/V (Rothan & Byrareddy, 2020.)
  • Strep Throat: Symptoms include sore throat, difficulty or painful swallowing, enlarged cervical lymph nodes, lack of cough, and fever (Thai, Dale & Ebell, 2018.)

Conclusion

HEENT symptoms can be caused by a variety of things. It’s important to assess the patient thoroughly in order to identify the reason and cause behind the symptoms the patient is experiencing. Upper respiratory infections can be viral or bacterial, and determining which one is important in order to move forward with the most appropriate treatment.

References

  • CDC. (2020, June 24). Testing for COVID-19. Retrieved July 2, 2020, from      https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html
  • Demarco, C. (2020, June 24). 10 things to know about COVID-19 testing. Retrieved July 3,        2020, from https://www.mdanderson.org/cancerwise/is-covid-19-coronavirus-testing-accurate-and-9-more-things-to-know-about-covid-19-nasal-swab-testing.h00-159381945.html
  • Rosenfeld, R. M. (2016). Acute sinusitis in adults. N Engl J Med, 375, 962-970.
  • Rothan, H. A., & Byrareddy, S. N. (2020). The epidemiology and pathogenesis of coronavirus   disease (COVID-19) outbreak. Journal of autoimmunity, 102433.
  • Schroeck, J. L., Ruh, C. A., Sellick, J. A., Ott, M. C., Mattappallil, A., & Mergenhagen, K. A.           (2015). Factors associated with antibiotic misuse in outpatient treatment for upper    respiratory tract infections. Antimicrobial agents and chemotherapy, 59(7), 3848-3852.
  • Stefaniuk, E., Bosacka, K., Wanke-Rytt, M., & Hryniewicz, W. (2017). The use of rapid test   QuikRead go® Strep A in bacterial pharyngotonsillitis diagnosing and therapeutic decisions. European Journal of Clinical Microbiology & Infectious Diseases, 36(10),   1733-1738.
  • Thai, T. N., Dale, A. P., & Ebell, M. H. (2018). Signs and symptoms of group A versus non-group A strep throat: a meta-analysis. Family practice, 35(3), 231-238.
  • Turner, R. B. (2015). The common cold. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 748.
  • Wheatley, L. M., & Togias, A. (2015). Allergic rhinitis. New England Journal of Medicine, 372(5), 456-463.

Next Week

To go to the next week:

Week 6