Week 5 Case Study: Episodic SOAP Note of a 50 Year-Old Male Presenting with Postnasal Drainage, Sneezing, Nasal Congestion, and Rhinorrhea

Week 5 Case Study: Episodic SOAP Note of a 50 Year-Old Male Presenting with Postnasal Drainage, Sneezing, Nasal Congestion, and Rhinorrhea

Week 5 Case Study: Episodic SOAP Note of a 50 Year-Old Male Presenting with Postnasal Drainage, Sneezing, Nasal Congestion, and Rhinorrhea

CASE STUDY 1: Focused Nose Exam
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.

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To Prepare

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.
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.
Here are some links and pertinent information, please use the book as one of the references
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 11, “Head and Neck”

This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.

Chapter 12, “Eyes”

In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.

Chapter 13, “Ears, Nose, and Throat”

The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.

Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.

Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.

Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.

Chapter 32, “Sore Throat”
A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.

Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)

Hayashi, T., Kitamura, K., Hashimoto, S., Hotomi, M., Kojima, H., Kudo, F., Maruyama, Y., Sawada, S., Taiji, H., Takahashi, G., Takahashi, H., Uno, Y., & Yano, H. (2020). Clinical practice guidelines for the diagnosis and management of acute otitis media in children—2018 update. Auris Nasus Larynx, 47(4), 493–526. https://doi.org/10.1016/j.anl.2020.05.019

Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.563627

Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031

Document: Episodic/Focused SOAP Note Exemplar (Word document)

Please use this template
Document: Episodic/Focused SOAP Note Template (Word document)

A Sample Of This Assignment Written By One Of Our Top-rated Writers

Case Study: Episodic SOAP Note of a 50 Year-Old Male Presenting with Postnasal Drainage, Sneezing, Nasal Congestion, and Rhinorrhea

Patient Information: Initials: R.J.     Age: 50 years old        Gender: Male

S.

CC (chief complaint): For five days, “itching palate, eyes, ears, and nose.”

HPI: The patient is a 50 year-old Caucasian male with the above presentation. He says he has no previous history of the same. The symptoms are domiciled in the ENT and the eyes and are intermittent in nature. The itchiness is characteristically severe and is aggravated by warmth. Taking a cold drink will relieve it temporarily. Symptoms are present any time day or night. He rates the symptom severity (the itchiness) at 8/10.

Current Medications:

• Over-the-counter (OTC) Mucinex 600 mg orally BID
• Tylenol 500 mg orally PRN

Allergies: He has no known allergies of any nature.

PMHx: Overweight, hypertension, and type II diabetes on both lifestyle interventions of exercise and diet as well as medications. He was fully immunized as a child and as an adult has received vaccination and booster shots for pneumonia, flu, and Covid-19.
Soc Hx: He routinely performs his aerobic and resistive exercises for 45 minutes each day from Monday to Saturday. He rests on Sundays. He denies taking alcohol or smoking cigarettes. He also denies a previous history of taking the same. He regularly meets friends over the weekends where some of them smoke but he does not. There are also admittedly those who take alcohol but he denies dong so himself. His hobbies include travelling, reading, watching movies, and fishing. He always wears a seatbelt when driving and never talks on the phone when doing so too.

Fam Hx: There is significant family history with regard to heart disease. His father died of stoke while his mother died of a myocardial infarct. He also has siblings that are overweight and also hypertension or in the pre-hypertension stage.

ROS:

GENERAL: Weight loss, fever, chills, weakness, or exhaustion are all denied.

HEENT: Eyes. Visual loss, blurred vision, double vision, or yellow sclerae are all denied. Hearing loss, sneezing, congestion, and sore throat are also all denied. He is positive for rhinorrhea.

SKIN: No rash or irritation on the skin, except on the sclera, nasal mucosa, external auditory canal, and throat where he feels an incessant itchiness.

CARDIOVASCULAR: Does not have chest pain, pressure, or discomfort. Palpitations and edema are not present.

RESPIRATORY: Difficulty breathing, cough, or sputum are not present.

GASTROINTESTINAL: Nausea, Anorexia, vomiting, or diarrhea are not present. She has no stomach pain or blood in her system.

GENITOURINARY: Denies urine hesitation, micturition regularity, dysuria, or burning sensation on micturition.

NEUROLOGICAL: Headache, dizziness, syncope, paralysis, ataxia, numbness, and tingling in the extremities are all denied. She hasn’t had any changes in her bowel or bladder control.

MUSCULOSKELETAL: Muscle, back, joint, and stiffness are not present.

HEMATOLOGIC: Anemia, bleeding, and bruising are not allowed.

LYMPHATICS: Prevents enlargement of lymph nodes. She has never had a splenectomy before.

PSYCHIATRIC: Denies having ever experienced sadness or anxiety.

ENDOCRINOLOGIC: Refutes perspiration, cold, or heat sensitivity claims. Polyuria and polydipsia are not present in her system. She also hasn’t had any hormone therapy in the past.

ALLERGIES: Denies having asthma, hives, eczema, or rhinitis in the past.

O.

Physical exam: Vital signs: BP 130/95 regular cuff and sitting; P 81, regular; T 98.3°F; RR 17, non-labored; BMI 27.6 kg/m² (overweight).

General: The patient was alert and oriented in time, space, place, person, and event. He was also appropriately groomed for the time of day and the season.

HEENT: Head normocephalic, PERRLA, EOMI. The nasal mucosa is pale and shows signs of a thin mucoid secretion. The throat has no obvious exudate but it is clearly erythematous. The nasal turbinates appear large and are definitely obstructing the flow of air into the nostrils.

Diagnostic results: CRP 3 mg/L; WBC 7,200; SpO₂ 93%. Endoscopy of the nose reveals inflamed nasal mucosa and enlarged turbinates (Hammer & McPhee, 2018; Mustafa & Ghaffari, 2020; Patel et al., 2020).

Differential Diagnoses

1. Rhinitis: Because it is known to produce irritation in the nose, eyes, ears, and palate, this is the most plausible clinical diagnosis (Hammer & McPhee, 2018; Mustafa & Ghaffari, 2020; Patel et al., 2020).
2. Sinusitis: Usually, sinusitis and rhinitis coexist as rhinosinusitis, resulting in identical symptomatology. As a result, it would be the next most likely clinical diagnosis (Hammer & McPhee, 2018; Mustafa & Ghaffari, 2020; Patel et al., 2020).
3. Ciliary dyskinesia: This is a disorder characterized by aberrant cilia and is linked to infections. Because it is generally associated with infertility, it is the least likely diagnosis since patient R.J. is a fertile man with children (Hammer & McPhee, 2018; Mustafa & Ghaffari, 2020; Patel et al., 2020).

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.563627

Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031