Allergic rhinitis
Instructions
Assignment:
-Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided.
-Provide evidence from the literature to support diagnostic tests that would be appropriate for the case.
-List five different possible conditions for the patient\’s differential diagnosis and justify why you selected each.
Case Study: 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.
*Attached is the template to fill out and will also be used to explain the possible diagnosis in APA format at the end of the SOAP note.
* There is also an example attached that you may use as a guide.
Solution
Episodic/Focused SOAP NoteFocused SOAP Note for a patient with respiratory complications S.CC: “I have nasal congestion, sneezing, rhinorrhea, and postnasal drainage.” HPI: Richard is a 50-years-old male who has come to the clinic complaining of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. As reported by Richard, he has struggled with an itchy nose, eyes, palate, and ears for 5 days. He has been taking Mucinex OTC the past 2 nights to help him breathe while he sleeps. However, the drug has caused only mild improvements. Medications: Mucinex OTC. FH: Father died of stroke at is 77 years old. Mother is 79 years old and was diagnosed with breast cancer 6 months years ago. She also has hypertension which she is managing using medications. Richard’s wife and three children are healthy. Allergies: No known food or drug allergies reported. Immunizations: Richard received all his childhood vaccines according to his medical records. Recent immunizations are influenza vaccine 26/11/2021; COVID-19 vaccine #1 3/12/2021 AstraZeneca; COVID-19 vaccine #2 5/17/2021 AstraZeneca. ROSGeneral: No abnormal changes in weight. Negative for fatigue or fever. Denies nausea and vomiting. Skin: No skin rashes, skin erythema, or abnormal changes in skin color. Denies changes in nail structure and appearance. HEENT:Head: Denies headache or head trauma/injury. Ears: Denies hearing loss. Denies changes in hearing or ringing in ears. Denies a history of ear infections. Neck: Denies lumps or swollen lymph nodes in the neck region Lymphatics: Denies swollen lymph nodes in neck area
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Pulmonary: Denies a cough or wheezing. Reports airway obstruction and difficult breathing. Reports a history of pneumonia.
Cardiovascular: Denies chest pain or dyspnea. Denies shortness of breath, tightness of the chest, or orthopnea. Does not report edema, hypertension, a history of a murmur, or known heart disease. Denies pain in posterior calves with walking or a history of an abnormal electrocardiogram.
Gastrointestinal: Reports mild pain in the throat while swallowing food. Denies food intolerance, heartburn, diarrhea, constipation, or indigestion.
Skin: Denies rashes or skin lesions.
Musculoskeletal: Denies joint pains or muscle stiffness.
Neurologic: Denies overall body weakness, dizziness, or headache.
Psychiatric: Denies depression, anxiety, insomnia, nightmares, or irritability.
O.
VS: BP 180/100; P 93; R 20; T 96.4; Wt 78.4 lbs.
General: Patient is alert and oriented to place, person, and time. Richard is well-groomed and neatly dressed.
HEENT: No signs of injury. He can hear properly. No issues have been observed in the eyes. Nasal mucosa is pale and boggy. The turbinates are enlarged and the nose produces clear thin secretions. His throat is mildly erythematous and there is evidence of airway obstruction. Tonsils are not enlarged.
Neck: No evidence of injury. No evidence of goiter.
Gastrointestinal: No bowel sounds. No evidence of abdominal distension.
Lungs/Respiratory: The lungs are clear. Evidence of airway obstruction.
Cardiovascular/Heart: No murmurs, no gallop.
Musculoskeletal: No evidence of joint stiffness or pain.
Peripheral Vascular: Limbs are sensitive to pain, heat, and cold.
Neurological: Oriented, alert, and with normal gait. No evidence of motor or sensory deficit observed.
Diagnostic results:
Inspection of the nasal septum: The septum is fairly straight and is close to the midline. No bleeding, perforation or deviation from the normal shape (Bickley et al., 2020).
Assess the middle turbinates using a head mirror: The nasal turbinates are enlarged (Dains et al., 2016).
Palpate the frontal and maxillary sinuses: The presence of pain, tenderness, or swelling is a sign of infection (Bickley et al., 2020; Ball et al., 2016).
Antibody test: IgE antibodies detected in the blood which confirms the presence of allergic rhinitis (Dains et al., 2016; Bickley et al., 2020).
A nasal smear test: Presence of eosinophils confirms the presence of allergic rhinitis (Bickley et al., 2020).
A.
Differential Diagnosis:
- Allergic rhinitis
- Nonallergic rhinitis
- Acute sinusitis
- Chronic sinusitis
- Turbinate hypertrophy
Primary Diagnosis/Presumptive Diagnosis:
Allergic rhinitis
Reference
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13th ed. Philadelphia: Wolters Kluwers.
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.