Focused Nose exam

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 in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.(Focused Nose exam Essay-Example)

–Examples of the template attached

Case Study 1: Focused Nose Exam

A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte 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.(Focused Nose exam Essay-Example)

·         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.

Resource

• 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 25  is attached

Focused Nose exam Essay-Example (Solution)

Episodic/Focused SOAP Note for Patient with Allergic Rhinitis

 Patient Information:

S.

CC: “I get this every spring, and it seems to last six to eight weeks.”

HPI: The patient is a 28-year-old Hispanic female presenting at the clinic complaining of a runny nose and itchy eyes. The patient states runny nose, itchy eyes, and ears felt full approximately 9 days ago. The patient reports experiencing this condition every spring, which lasts six to eight weeks. She describes the nose as runny with clear mucus. Sneezes on and off all day. Her eyes itch so bad she wants to scratch them out, sometimes feels a tickle in her throat, and her ears feel full and sometimes pop. Last year she took Claritin with relief.(Focused Nose exam Essay-Example)

Current Medications: Acetaminophen 325mg

Allergies: Dust and pollen.

PMHx: Positive history of Covid-19, controlled and vaccinated.

FH: Father, at 66, has a history of kidney stones. Mother died when 37 from an accident, and she has no known medical history
Soc Hx: Negative history of tobacco, alcohol, or substance use. Married and living with the husband.(Focused Nose exam Essay-Example)

ROS

GENERAL:  Denies weight loss, fever, chills, weakness, or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Reports itchy eyes.

Ears, Nose, Throat:  Denies hearing loss. Reports feelings ears are full. Reports sneezing and denies congestion. Reports runny nose and scratchy throat. The throat is mildly erythematous.(Focused Nose exam Essay-Example)

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY:  Reports shortness of breath due to blocked airways and sneezing intermittently throughout the day. Denies cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Denies burning on urination, pregnancy. Last menstrual period, 27/02/2023.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.(Focused Nose exam Essay-Example)

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding, or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies a history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Dust and pollen.(Focused Nose exam Essay-Example)

O.

VS: Temp: 97.8F, B.P.: 110/70, P: 85, R.R.: 19, O2: Room air, Pain: 0/10, Ht: 5’9 feet, Wt: 170 lbs, BMI: 25.1, BMI Range: Overweight

Physical exam: Alert and oriented

HEENT: Her throat was mildly erythematous without exudate. Nasal mucosa was pale, boggy, and erythematous, with clear thin secretions and enlarged nasal turbinates. Only clear drainage was seen. TMs were clear.

Neck: Supple without adenopathy.

Lungs: Clear.

A.

Differential Diagnoses:

1) Allergic Rhinitis: Allergic rhinitis occurs in the eyes, nose, and throat when airborne allergens cause the body to release histamine. Pollen, dust mites, mold, cockroach feces, animal dander, fumes and aromas, hormonal fluctuations, and smoke are some of the most typical triggers of rhinitis(Focused Nose exam Essay-Example). Sneezing, a stuffy, runny, and itchy nose, itchy throat, eyes, and ears, nosebleeds, clear drainage from the nose, recurrent ear infections, snoring, mouth breathing, and fatigue are all signs of allergic rhinitis (Akhouri et al., 2022). The patient presents with itchy eyes and ears, a runny nose with clear discharge, and a sore or itchy throat, guiding the diagnosis of allergic rhinitis, which seems to affect the patient only in spring, implying pollen-induced allergic rhinitis.(Focused Nose exam Essay-Example)

2) Vasomotor rhinitis: The most prevalent type of nonallergic rhinitis, vasomotor rhinitis, is diagnosed as an exclusion. Nonallergic rhinitis has a complicated pathogenesis that is still being studied (Leader & Geiger, 2022). The nasal mucosa’s parasympathetic and sympathetic inputs are out of balance, contributing to this condition. In allergic and nonallergic rhinitis, headache, face pressure, postnasal drip, coughing, and throat clearing are typical symptoms. According to the predominating symptomatology, patients with vasomotor rhinitis are typically divided into “blocks” with congestion and “runners” with rhinorrhea. Rhinorrhea patients frequently exhibit an intensified cholinergic response (Leader & Geiger, 2022). Nociceptive neurons in people with nasal blockage may respond more strongly to benign stimuli. This diagnosis was refuted because the patient indicated she experiences the symptoms during spring; hence the cause is known.(Focused Nose exam Essay-Example)

3) Acute Sinusitis: Acute sinusitis is an infection of the sinuses. It involves sinus passageways and nasal passages, which are connected. Purulent nasal discharge, nasal blockage or discomfort, pressure, or fullness in the face, are the three core symptoms most sensitive and specific for acute rhinosinusitis (DeBoer & Kwon, 2019). Patients who could present with general “headache” concerns help to clarify this because an isolated headache is not a symptom. However, sinusitis can be characterized by isolated facial pressure. This diagnosis was refuted because the nasal discharge was clear.(Focused Nose exam Essay-Example)

4) Rhinitis Medicamentosa: Rebound congestion, commonly known as “rebound rhinitis medicamentosa,” is an inflammation of the nasal mucosa brought on by excessive consumption of topical nasal decongestants. It is categorized as a form of drug-induced rhinitis(Focused Nose exam Essay-Example). While using an intranasal decongestant for an extended period, the patient often experiences a recurrence of nasal congestion, especially without rhinorrhea (Wahid & Shermetaro, 2021). Snoring, oral breathing, and dry mouth are all symptoms of severe nasal congestion. A clinical examination will show swollen, erythematous, and granular nasal mucosa. Furthermore, pale and edematous looks can be noticed (Wahid & Shermetaro, 2021). The nasal membrane is crusty and atrophic as the condition worsens. The diagnosis was refuted because the cause is established as pollen common during spring and not any medication.(Focused Nose exam Essay-Example)

5) Hormone-Induced Rhinitis: Hormone-induced rhinitis is marked by congestion and nasal symptoms brought on by endogenous female hormones, such as those present during pregnancy. Patients with a history of craniofacial trauma or prior facial surgery with persistent, clear rhinorrhea should be evaluated for a cerebrospinal fluid (CSF) leak (Liva et al., 2021). This diagnosis was ruled out because the patient denied pregnancy, minimizing the likelihood of being affected by endogenous female hormones. Also, the patient has no surgical history.(Focused Nose exam Essay-Example)

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Akhouri, S., House, S. A., & Doerr, C. (2022). Allergic rhinitis (nursing). In StatPearls [Internet]. StatPearls Publishing.

DeBoer, D. L., & Kwon, E. (2019). Acute sinusitis. In StatPearls [Internet]. StatPearls Publishing.

Leader, P., & Geiger, Z. (2022). Vasomotor rhinitis. In StatPearls [Internet]. StatPearls Publishing.

Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of Rhinitis: Classification, Types, Pathophysiology. Journal of clinical medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183

Wahid, N. W. B., & Shermetaro, C. (2021). Rhinitis medicamentosa. In StatPearls [Internet]. StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/