Assessing, Diagnosing, and Treating Patients With HEENT Conditions
Create a SOAP note for this case and note any influence of social determinants of health and relevant referrals
Ms. Vitatony arrives at the primary care clinic via a Medicaid approved transporter van. The private clinic markets itself as a clinic for seniors, an increasingly popular marketing concept. You are newly employed at the clinic as a nurse practitioner. Ms. Vitatony checks in at the front desk as a new patient, saying she lives close by and Medicaid approved transportation to this clinic. In the exam room she tells you that she is 71 years old, is a retired housekeeper, can make ends meet only because she lives in the house willed to her by her grandfather many years ago. Grandparents and parents all died of old age. She has no siblilngs. Her income is a small Social Security check and she does not have to work, However, she is on her \”second round\” of baby-sitting for her grandchildren. Two, she cared for as babies are in school, but she now has two more babies, 3 months and 10 months old, children of her grandchildren. She feels weak and tired all the time. For two days she has been coughing and sneezing. She has been having headaches over her eyes and last night she had a chill. She tells you she is worried and cannot sleep at night. This is her family and she wants to help them. Both sets of parents have had COVID, they think, as they were sick but not tested. Ms. Vitatony worries about the person who came to fix her door last week after someone attempted to break in. She tells you she learned today that he is in the ICU on a ventilator with COVID. He had told her he was not going to be vaccinated. Ms. Vitatony has had two COVID vaccinations from the senior center on her block but she has not the booster. She has not had a flu shot. She tells you she is aware that she is high risk at her age with her condition of high blood pressure and asthma. She saw this on the local TV news. Her family members tell her that COVID is over-rated, that they had it and are fine. They just want her to take some vitamins, stop worrying, and focus on the children. None of the four parents would drive her today as they have no time off from work. She came in the Medicaid van while a neighborhood teen is watching the babies. She tells you the teen has been vaccinated. She hands you her medications and asks what she should do in case she has COVID. She asks to be treated as quickly as possible as she has little time.
Medications
HCTZ 25 mg daily, Losartan 50mg daily, Lexapro 10 mg daily, MVI daily, Calcium 18 mg daily, Melatonin 6 mg nightly, Tylenol 10 mg every 6 hours as needed for pain. She also has an oxygen concentrator for shortness of breath that she does not use, and an inhaler which she uses at night but left behind today.
Complete a SOAP Note.
Include social determinants of health in the history and the plan. Would you need to know more about her social determinants of health? What are the priorities as you review the information you have? What exam(s) would you do? What tests? Consider who, if anyone, you might consult, interdisciplinary professionals or others. What/when/how should she be seen for/if follow up? What is your reflection upon completing this case? Reflect upon your thinking after you completed this visit.
Focused SOAP Note Template
Patient Information:
Initials Ms. V, Age- 71 years old, Sex- Female, Race- African American
S.
CC (chief complaint): The patient feels weak, tired, coughing and sneezing for the last 2 days, severe headaches over her eyes and a chill.
HPI:
Location: head
Onset: 2 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: coughing, sneezing, severe headaches and a chill
Timing: most of the time
Exacerbating/relieving factors: N/A
Severity: 8/10
Current Medications: HCTZ 25 mg daily, Losartin 50 mg daily, Lexapro 10 mg daily, MVI daily, Calcium 18 mg daily, Melatonin 6 mg nightly, Tylenol 10 mg every six hours. Oxygen concentrator and an inhaler.
Allergies: Is asthmatic.
PMHx: The patient has a history of high blood pressure and asthma. She had two COVID-19 vaccinations though she has not had a booster shot.
Soc & Substance Hx: Ms. V is a babysitter for her grandchildren. She takes care of two children aged 3 months and 10 months. She relies on a small Social Security check since she does not have work. Besides babysitting, she enjoys spending time with her family. She enjoys spending time with her family. She has a strong support system from her children and grandchildren.
Fam Hx: Ms. V has high blood pressure and asthma. Her mother who passed on 5 years ago succumbed to natural causes of death.
Surgical Hx: No history of prior surgical procedures
Mental Hx: Has no mental health diagnosis. She does not have a history of depression or anxiety. She has not engaged in self-harm practices in the past or expressed any suicidal ideation.
Violence Hx: The patient has no history of violence. She however has issues regarding her safety as someone tried to break in last week.
Reproductive Hx: Ms. V is in her menopause. She is not sexually active.
ROS:
GENERAL: Has chills, weakness, and fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, is sneezing and coughing, no congestion, no runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, has a cough but no sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: Has severe headache over the eyes. No 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.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety. She has however been experiencing worry about her recent symptoms.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal discharge. Not sexually active.
ALLERGIES: Has asthma and uses an inhaler.
O.
Physical exam:
Vitals: BP 140/90, P 99, Weight 160, Height 5’6”
General: Weakness, fatigue, and tired all the time
HEENT: Sneezing
Respiratory: Coughing
Neurological: Severe headaches over the eyes
Diagnostic results:
Polymerase chain reaction test
Antigen test
Nucleic amplification tests
A
Differential Diagnoses:
Influenza
Influenza is the first differential diagnosis based on the patient’s symptoms and health history of no vaccination against flu. Influenza refers to a viral infection that is caused by either the influenza A or B virus (Moghadami, 2017). The condition usually affects the upper respiratory organs like the nose, throat, and bronchi. The condition usually spreads from one to the other through droplets from coughs or sneezes. The symptoms include headache, fever, dry cough, runny nose, sore throat, and severe malaise.
COVID-19
COVID-19 is an acute viral respiratory tract infection whose clinical manifestations include fever, dry cough, sore throat, fatigue, headache, and shortness of breath among others (Wu et al., 2020). The virus belongs to the Orthocoronavirinae subfamily which looks like they have crown-like spikes on the surfaces. It is important to note that despite the patient having being vaccinated, she has come into contact with someone with the COVID-19 virus.
Adenovirus
Adenovirus refers to double-stranded DNA viruses which are linked with illnesses of the upper respiratory tract. Adenoviral infections can also show gastrointestinal, ophthalmologic, genitourinary, and neurological symptoms. The condition affects mostly vulnerable populations like children, the elderly, and those living with suppressed immunity
Influenza can be managed by the use of cough medicine, nonsteroidal anti-inflammatory drugs which relieve pain and decreases inflammation, analgesics like Tylenol that reduces pain and fever, and supportive care like fluid intake.
The Food and Drug Agency has only approved one medication, Remdesivir (Veklury) for the treatment of COVID-19 for individuals older than twelve years. Patients diagnosed with the virus but showing mild symptoms that used supportive care such as pain relievers, cough syrup, fluid intake, and rest to manage the illness.
Adenovirus is managed by antiviral agents like cidofovir, supportive care like adequate hydration, analgesics, and oxygen supplementation if need be (Khanal et al., 2018).
The patient’s health history indicates that she has asthma and blood pressure. Similarly, she has not had a flu jab recently. Her age of 71 years makes her vulnerable to opportunistic infections. Her lack of work and financial stability act as vital social determinants of health which could hinder her access to quality and regular healthcare services. There would be a need to incorporate a multifaceted approach to managing the patient’s health status. For example, there is a need to recommend the use of pharmacological agents, lifestyle modification, and patient education on how to protect herself from COVID-19 by wearing masks and limiting interactions with people.
The patient was advised on the importance of follow-up visits to the clinic to monitor her health and especially the response to drugs. She was also advised to monitor her blood pressure levels regularly. Similarly, in case she experiences additional respiratory symptoms like shortness of breath, she should seek medical attention to prevent complications.
Reflection
The patient understood her health risks especially at her old age and due to having pre-existing conditions. She, therefore, agreed to adhere to medications, lifestyle modification as well as taking extra caution, especially during the COVID-19 pandemic.
References
Khanal, S., Ghimire, P., & Dhamoon, A. S. (2018). The Repertoire of Adenovirus in Human Disease: The Innocuous to the Deadly. Biomedicines, 6(1), 30. https://doi.org/10.3390/biomedicines6010030
Moghadami M. (2017). A Narrative Review of Influenza: A Seasonal and Pandemic Disease. Iranian journal of medical sciences, 42(1), 2–13.
Wu, Y. C., Chen, C. S., & Chan, Y. J. (2020). The outbreak of COVID-19: An overview. Journal of the Chinese medical association, 83(3), 217.