Walden Unviversity – NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat

Walden Unviversity – NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat – Focused Soap Note

Walden Unviversity – NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat

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

Help with a Focused Soap Note

Focused SOAP Note for a patient with chest pain

S.

CC: “nasal congestion and rhinitis * 5 days”

HPI: The patient is a 50-year old person who presented to the clinic suffering from rhinorrhoea, nasal congestion, postnasal drainage as well as sneezing. The patient has struggled with the itchy palate, nose, as well as eyes for a period of 5 days. Moreover, he suffers from a pale, boggy nasal mucosa alongside enlarged turbinate as well as clear thin secretions. The tonsils are not enlarged; though, he has mild erythematous in his throat.

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Medications: Mucinex

PMH: No significant medical history. The patient denies having been admitted or undergoing surgical intervention in the last 2 years. He is up to date on his immunization.

FH: Both of the patient’s parents are alive. The patient is married and they have two children aged 14

and 12. He has two siblings who are aged 42 and 46 years. They are all healthy, except the mother who presents with breast cancer.

SH:  The patient denies smoking. He indicates that he quit smoking in 2006. On the other hand, he occasionally drinks alcohol.  The patient engages actively in religious activities. The patient understands the importance the eating healthy and engaging in regular physical exercise.

Allergies: NKDA, indicates seasonal allergic reactions.

Immunizations: n/a

ROS  

The general-The patient is well-groomed and oriented. He denies fever or fatigue. He is AAOX 4.

HEENT: The patient denies headache, but the eyes are itchy and red. There are no changes in the visual acuity. The tympanic membranes are intact with no hearing changes. The patient has nasal congestion and itchy nasal mucosal. The nasal turbinate is also enlarged.

Cardiovascular–Negative chest pain, no palpitations.

Gastrointestinal– No nausea, non-distended abdomen.

Pulmonary– negative for dyspnea or hemoptysis. NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat

 O.

VS: BP 121/82; P 67; R 20; T 97.8; 02 96% Wt 191lbs; Ht 70”

General-The patient denies weakness or fatigue. He is well-groomed and nourished.

Cardiovascular- No chest pain or cyanosis noted in the patient.

HEENT: Eyes are itchy and red. The tympanic membranes are intact with no discharge. No tonsillitis or purulent discharge was produced. The throat is moderately erythematous. Enlarges nasal turbinate with clear thin secretions.

Gastrointestinal-The abdomen is symmetrical and non-distended.

Pulmonary– Lungs are clear to auscultation, no chest pain or murmuring sound produced.

Diagnostic results: Skin test positive for allergy, Allergen-specific IgE antibody test not done.

A.

Differential Diagnosis:

• Allergic rhinitis: The condition is characterized by sneezing and nasal congestion. The condition result from inhalation of allergens. Most of the symptoms indicated by the patient are consistent with the allergic rhinitis and this could be the most possible diagnosis (Hoyte & Nelson, 2018).
• Sinusitis: The condition is characterized by the inflammation of the sinuses due to bacterial or viral infection. The common symptoms of the disease include nasal congestion, itchiness, and reddening. Also, the patient may have facial pain and pressure (Almutairi et al., 2018).
• Common cold: Common cold is caused influenza virus. The virus is limited to the sinuses and is mainly spread through contact. The symptoms include nasal congestion, fever and headache (Singh et al., 2017). The patient denied fever and headache in this case.

1. Administer nasal corticosteroids with oral antihistamine (Urrutia Pereira, 2018).

 References

Almutairi, M. B., Alsulaimi, S. M., Alghamdi, R. A., Alrehaili, K. A., Habhab, S. A., Althagafi, A. M., Alghamdi, F. A., Meighrbl, N. A., Alsuhaymi, W. M., & AlYahya, M. S. (2018). Evaluation of GERD diagnosis, management, and outcomes. The Egyptian Journal of Hospital Medicine, 72(9), 5195-5202. https://doi.org/10.21608/ejhm.2018.10741

Hoyte, F. C., & Nelson, H. S. (2018). Recent advances in allergic rhinitis. F1000Research, 7, 1333. https://doi.org/10.12688/f1000research.15367.1

Singh, M., Singh, M., Jaiswal, N., & Chauhan, A. (2017). Heated, humidified air for the common cold. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd001728.pub6

Urrutia Pereira, M. (2018). Knowledge of pharmacists about allergic rhinitis and its impact on asthma guidelines (Aria guidelines): A comparative Brazilian/Paraguayan pilot survey. https://doi.org/10.26226/morressier.5acc8ad0d462b8028d89aaca