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

Episodic/Focused SOAP Note

Patient Information:

Lily 20yr Female

SUBJECTIVE DATA

Chief Complaint: “Sore throat”

History of Present Illness (HPI): Lily is a 20-year-old Caucasian woman who comes to the facility complaining of a posterior sore throat that began approximately 3 days ago and has persisted. Patient has also reported a runny nose, soreness while swallowing, and a diminished appetite. The painful throat is severe in the morning before eating anything. The client has been using Cepacol lozenges to relieve the sore throat, which has helped to minimize the discomfort in the throat marginally. She gives her pain a 6 out of 10 rating on a pain scale Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat.

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Current Medications: Cepacol lozenges.

Allergies: NKDA

PMHx: Denies past medical history. All significant immunizations are current. Influenza 6/11/2021 and Tetanus December, 2020.

Social History: She is presently a student at a local college. She is very hardworking and involved in her academics. She participates in basketball and community service activities on a regular basis. She goes out with friends once a week to have a drink. She denies tobacco and illicit drug use. She is in a heterosexual relationship with her lover. She is sexually active and does not use any kind of contraception.

Family History: Father 63 years old, history of alcohol abuse; mother 56 years old, history of hypertension. Has a 16 year old sister in good health Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat.

Review of Systems

GENERAL: Denies fever or weight change. Reports occasional fatigue.

HEENT: Denies visual problems. Denies hearing loss. Reports runny nose. Reports sore throat with hoarseness.

Skin: Denies itching or rash.

CARDIOVASCULAR: Denies chest pain or pressure. Denies palpitations or edema.

RESPIRATORY: Denies cough or shortness of breath.

GASTROINTESTINAL: Denies nausea, vomiting, or diarrhea. Denies abdominal pain.

GENITOURINARY: Denies polyuria, dysuria.

NEUROLOGICAL: Reports headache. Denies ataxia, paralysis, syncope, or dizziness.

MUSCULOSKELETAL: Denies joint, back or muscle pain.

HEMATOLOGIC: Denies bleeding, anemia, or bruising.

LYMPHATICS: Denies splenectomy.

PSYCHIATRIC: Denies history of anxiety, depression, or suicidal ideation.

ENDOCRINOLOGIC: Denies sweating, heat or cold intolerance. Denies polyuria or polydipsia.

ALLERGIES: Denies history of asthma, eczema, rhinitis, or hives.

OBJECTIVE DATA

Physical Exam:

Vital signs: Bp: 125/76, HR: 88, RR: 18, T: 98.8, Ox sat: 97%, weight 127.38lbs, Height 5’6’’

General: Patient appears stable and in no acute distress

HEENT: Nose: clear drainage noted.No erythema present in the nares. Throat: erythema in pharynx noted, no exudate or tonsillar swelling noted.

Lungs: S1, S2 clear to auscultation. No rhonchi or crackles.

 

Diagnostic Results: CBC, nasal smear, rapid flu nasal swab, rapid strep antibody and culture pending.

ASSESSMENT

Differential Diagnoses

  1. Viral Pharyngitis- Viral pharyngitis is characterized by a painful throat that is associated with soreness, coarse texture, or inflammation of the throat, which is exacerbated when one swallows. Common cold viruses are the leading cause of sore throats. In most cases, a sore throat triggered by a virus will go away by itself. Rhinorrhea headache, body pains, nausea, and other indications may also be present in viral pharyngitis (Horton et al., 2020). The presence of viral pharyngitis cannot be confirmed by a diagnostic test. Nevertheless, the practitioner must eliminate the chances of other ailments including influenza, strep throat, etc. to appropriately diagnose the disease.
  2. Strep throat- Strep throat is a condition that results in a painful throat. It is a bacterial infection caused by the group A streptococcus bacterium (Thai et al., 2017). Fever, intense sore throat, and lethargy are just a few of the signs and symptoms that might appear unexpectedly or develop gradually. Patients who are thought of having strep should have a quick strep throat swab performed, and if the findings are positive, they may be managed without further culturing (Sykes et al., 2020) Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat.
  3. Influenza- influenza is a viral illness that affects the nose, throat, and airways (Gaitonde et al., 2019). A runny nose, coughing, and sore throat are all symptoms of influenza at first glance, and it may be mistaken for a common cold. While influenza might appear abruptly, the development of a cold is more gradual. Throat swab or rapid influenza nasal tests are among the available diagnostic options.

References

Gaitonde, D. Y., Moore, F. C., & Morgan, M. K. (2019). Influenza: diagnosis and treatment. American family physician, 100(12), 751-758. https://www.aafp.org/afp/2019/1215/p751.html

Horton, G. A., Simpson, M. T., Beyea, M. M., & Beyea, J. A. (2020). Cerumen management: An updated clinical review and evidence-based approach for primary care physicians. Journal of Primary Care & Community Health, 11, 215013272090418. https://doi.org/10.1177/2150132720904181

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145142/

Thai, T. N., Dale, A. P., & Ebell, M. H. (2017). Signs and symptoms of Group A versus non-group a strep throat: A meta-analysis. Family Practice, 35(3), 231-238. https://doi.org/10.1093/fampra/cmx072

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat To Prepare • 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. Concerning 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. The 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 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. CASE STUDY: – Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn’t take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and slight hoarseness in her voice but doesn’t sound congested. Please utilize the Template below: Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance, “headache”, NOT “bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat.

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If the CC was a “headache”, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers the eyes, for example, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency, length of time used, and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance). PMH: include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo questions here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. The reason for the death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: Denies weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat Denies hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: Denies rash or itching. CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat.

RESPIRATORY: Denies shortness of breath, cough, or sputum. GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. 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 history of depression or anxiety. ENDOCRINOLOGIC: Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis. O. Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e. General: Head: EENT: etc. Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines) A. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines. References (On separate page) You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat