Assessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment

chard 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 two 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 areAssessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment not enlarged but his throat is mildly erythematous.

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Episodic/Focused SOAP Note Patient Information: R.J. 50-year-old Caucasian Male.

Subjective.

CC: “ Has struggled with an itchy nose, eyes, palate, and ears for 5 days and is sneezing too,”

HPI: R.J, who is fifty years old complains that in the last five days, he has recorded cases of rhinorrhea, itchy nose, ears, nasal congestion, postnasal drainage. In helping him breath, RJ has been taking Mucinex OTC which has not been very helpful. He denies cases of headache or any other pain.

Medications: One tab of Mucinex OTC that is taken through the mouth in every night.

Allergies: He has does allergies that are seasonal.

PMHx: Denies to have gone for any surgery or become very ill. Had been bedridden in hospital in 2006 after getting involved in a plane crash. Took all immunization and vaccinations and he received the Covid-19 shot 5 months ago.

Soc Hx: He is a father of three children aged 13, 10 and 7 and is married to one wife who is 40 years old. Is not currently smoking but in the past he used to smoke. Is not an often drinker of alcohol? Is working as a manager in one local company and is a holder of diploma in human resource. He is a big fun of swimming and horse riding accompanies with his family members. He physically active in sports such as football and he eats healthy diet. He gets enough sleep but this has not been possible in the last 5 days since he started getting the symptoms. Assessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment

Family History: Both the father and his mother are alive but his father has high blood pressure which is well controlled. His mother has diabetes which is also well controlled. His two brothers have not significant illness. Besides, his children have no significant health issue. His grandparents passed away 15 years ago through road accident.

ROS

General: AAO X 3, is dressed well, no chills, fever or fatigue. Looks sleepy as a result of lack of adequate sleep.

HEENT: Has eyes that are red and itching. Denies having headaches.

PERRLA, the vision is normal with no changes. The changes in hearing and the eyes are not discharging any fluid. no vision changes. Tympanic membranes are intact, no changes in hearing, no discharge from ears. The nose is itching and congested. The nasal mucosa is pale and the nasal turbinate are larger than usual.

Throat has no enlarged tonsils.

Neck: The lymph nodes are not swollen and the trachea is in the middle of the neck. Assessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment

Skin: There are no rashes or itching on the skin. The turgor of the skin is tight. He skin has not changed its color.

Cardiovascular:  The pain is not in pain, discomfort or extra or abnormal pressure. There are no palpitations nor any kind of edema.

Respiratory: No coughing or dyspnea.

Musculoskeletal: the muscles are not paining. The joints are also not in pain nor stiffness. Has no excessive stiffness in the muscles of the patient.

Lymphatics: The nodes have not enlarged.

Allergies: Reports dust allergies that is seasonal.

Objective. Physical Exam:

General: The patient is denying fatigue or weakness. AAO X 4. He is well nourished and properly dressed.

V/S: Temperature: 89 degrees Fahrenheit, Pulse rate is: 71 beats/minute and the rate is regular, Respiration rate: 15 breaths/minute, BP: 119/78, Weight: 188 lbs.

HEENT: His head is normocephalic. His eyes are reddish and itching.

Tympanic membranes do not show any bad feature and has no drainage. There is a presence of pale and boggy mucosa that is congested. The nose is also producing thin and clear liquid.

Rhinorrhea. The throat does not have tonsillitis, nor abnormal discharge nor bleeding.

CV: The chest is not painful or have any discomfort, edema or any kind of palpitation.

Respiratory: The patient does not record any dyspnea or S.O.B. There is clear and easy entry of air in the nose and the lung lobes are very clear. The expansion of the patient’s lungs is equal. Assessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment

Musculoskeletal: There is no pain that is recorded in the skeleton and its motion is good, symmetric and strong.

 Lymphatics:  There is no signs of enlargement of the nodes and the patient has never had splenectomy. No enlarged nodes.

Allergies: Has allergies of dust that comes seasonally but has no history of having allergies associated with drugs.

Diagnostic Results:

Skin Test: The skin test is indicating positive to the pollen.  The health history only can be used to diagnose allergic rhinitis (Dodi, 2017). In case the patient does not show any improvement when receiving medication, diagnostic testing can be done. Another test that can be used to the patient is ski test to find out the patients’ reaction to dust. Such test can be used to administer further medication. Skin testing is one of the most important method to discriminate subjects that have or do not have allergic rhinitis.

Allergen-specific analysis was not done. This kind of testing is often done if other testings are not practical or in other instances such as when the patient is under medications that can alter their skin testing. Assessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment

Differential Diagnosis:

Allergic Rhinitis:

There are many definitions of allergic rhinitis but it can be basically described as the sets of symptoms and signs that make the patient sneeze, have obstruction of airflow and discharge clear nasal liquid caused by type II helper cells (Vazquez, 2019).  This is a clear indication that the conditions of the is Dx as a result of positive skin tests as well as the patient’s clinical history.

Non-Allergic Rhinitis:

This condition just as allergic rhinitis can be diagnosed through the analysis of the health history of the patient (Naclerio & Pawankar, 2014).  The condition is proven to be non-allergic as a result of failure to clinically respond to the medication for the thought allergic rhinitis and negative outcome from the skin test. This DX is on high likelihood but the test of the skin is confirming allergy to the skin.

Sinusitis:

This can be described as the inflammation that is present on the paranasal sinuses that is highly associated with infections from infections or bacteria or any other reaction from allergies. This condition has different signs and symptoms such as headaches, nasal congestion and obstruction and fever. The Dx is not likely because of lack of S as well as Sx type of infection. Assessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment

Common Cold: This can be described as an acute infection that is caused by virus and is self-limiting that affect the upper part of the respiratory tract that connects the nose, larynx, sinuses as well as pharynx (Hopp, 2017). The spread of the virus is mostly done through hand contact with the mucus or any other secretion from the person who is already infected. Ths Dx is not likely since the symptoms of the patient has been on for the last five days. The patient also does not indicate any sign of malaise or fatigue.

Tonsillopharyngitis:

This condition is also known as sore throat. Often, this condition causes pain in the posterior pharynx when one is both swallowing or not. The condition is mostly caused by viruses but there are a few causes of bacterial infections. The Dx is not likely since the patient does not record sore throats or pain, no tonsils that are enlarged and there is no S and Sx of infection. Assessing the Head Eyes Ears Nose and Throat Focused SOAP Note assignment

Plan: This is a nasal corticosteroids or in some instance the oral antihistamines that often has decongestants.

References

Dodi, I. (2017). Pediatric acute tonsillopharyngitis managemnent and treatment: Regional guidelines, Emilia – romagna Italy. https://doi.org/10.26226/morressier.58fa1767d462b80290b51519

Hopp, R. (2017). Pediatric chronic sinusitis: What art thou? Sinusitis, 2(3), 6. https://doi.org/10.3390/sinusitis2030006

Naclerio, R. M., & Pawankar, R. (2014). Allergic rhinitis. Asthma, 231-243. https://doi.org/10.1093/med/9780199918065.003.0018

Vazquez, F. (2019). Sinusitis to relaunch. Sinusitis, 4(1), 1-1. https://doi.org/10.3390/sinusitis4010001

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