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 nine days ago. “I get this every spring, and it seems to last six to eight weeks.” Describes 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 took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, obstructing airway flow, but his lungs are clear. His tonsils are not enlarged, but his throat is mildly erythematous.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

Nurses conducting assessments of the ears, nose, and throat must be able to identify the slight differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a good patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

  • Case Study Assignments 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 in every patient case—document in SOAP note format. You must make up information to complete the SOAP note, do not leave blank sections or say N/A.
  • Provide a detailed assessment of the affected system. Always include General, CV, and Respiratory assessment in each Focus note.
  •  Mayo and Cleveland Clinic are not Scholarly Resources. Use more than one scholarly resource.
  • Provide evidence from the literature to support diagnostic tests appropriate for each case.
  • 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.

Answer

Focused Nose Exam

Patient Information:

Patient Initials: C. S Age: 28 Gender: Female Race: White American

SUBJECTIVE DATA:

Chief Complaint (CC): The patient presents with a complaint of a runny nose and itchy eyes.

History of Present Illness (HPI): The patient presents with a runny nose and itchy eyes. She reports experiencing these symptoms for approximately nine days. The patient mentions that this is a recurring issue that she typically experiences every spring, lasting six to eight weeks. She describes her nose as constantly runny, with clear mucus. She also experiences intermittent sneezing throughout the day. The patient complains of intense itching in her eyes, so she feels the urge to scratch them excessively. Additionally, she occasionally feels a tickle in her throat and describes her ears as full, sometimes experiencing a popping sensation. The patient states she found relief from similar symptoms last year by taking Claritin.

Medications:

  1. Metformin
  2. Combined oral contraceptives

Allergies: No known drug or food allergy.

Past Medical History (PMH): Ms. C.S. was diagnosed with PCOS in her early 20s. She reports irregular menstrual cycles, hirsutism, and occasional acne breakouts. She has previously been prescribed oral contraceptives and metformin to regulate her periods and manage the symptoms associated with PCOS.

Past Surgical History (PSH): No past surgical history

Sexual/Reproductive History: Ms. C.S. experienced menarche at 13 and has had irregular menstrual cycles. She is currently unmarried and has not pursued any forms of assisted reproductive technology. However, she has expressed a desire to start a family and is seeking guidance regarding fertility options and the management of her PCOS symptoms.

Personal/Social History: The patient is a non-smoker and does not consume alcohol or recreational drugs. She works as a marketing executive and spends most of her time indoors in an office. The patient reports no known allergies to food, medications, or environmental triggers besides her seasonal allergies. She mentions that she enjoys spending time outdoors but tries to limit her exposure during the spring when her symptoms peak. The patient reports a regular sleep schedule and denies significant stressors or recent changes.

Immunization History: According to the patient’s records, she is current with her routine immunizations. She received the recommended childhood vaccinations, including measles, mumps, rubella (MMR), diphtheria, tetanus, pertussis (DTaP), polio, hepatitis B, and varicella. The patient has also received the annual influenza vaccine in the past. However, she mentions that she has not received any immunizations targeting seasonal allergies.

Significant Family History: The patient’s father and maternal grandfather have a history of seasonal allergies with symptoms similar to the patient’s current presentation. Her younger brother also experiences similar allergic symptoms during the spring season. There is no known history of chronic or severe respiratory conditions among immediate family members.

Review of Systems:

General: The patient denies any recent weight changes, weakness, fatigue, or fever

HEENT:

Head: No head trauma or headaches were reported. There is no significant headache, facial pain, or pressure.

Eyes: The patient complains of intense itching in her eyes.

Ears: The patient describes her ears as feeling full and occasionally experiencing a popping sensation. The patient denies any hearing loss, tinnitus, or ear discharge.

Nose: The patient reports a constantly runny nose with clear mucus. She also experiences intermittent sneezing.

Throat: The patient occasionally feels a tickle in her throat. There is no sore throat, difficulty swallowing, or voice changes.

Respiratory: The patient denies shortness of breath, cough, wheezing, or chest pain. No history of chronic respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD) is reported.

Cardiovascular/Peripheral Vascular: The patient denies chest pain, palpitations, or peripheral edema. No history of cardiovascular diseases, such as hypertension or heart failure, is reported. The patient does not report any leg pain, claudication, or swelling.

Psychiatric: The patient denies any symptoms of anxiety, depression, or changes in mood. There is no history of psychiatric disorders or current medication use for psychiatric conditions.

Neurological: The patient does not report any recent changes in sensation, motor function, or coordination. There are no episodes of dizziness, syncope, or seizures.

Lymphatics: The patient does not report enlarged or palpable lymph nodes.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: Blood pressure: 120/80 mmHg, Heart rate: 80 beats per minute, Respiratory rate: 16 breaths per minute, Temperature: 98.6°F (37°C), Height: 5 feet 6 inches, Weight: 140 lbs, BMI: 22.6 kg/m², Pulse oximetry: 98% on room air.

General: The patient appears alert and oriented. She is in no apparent distress. Her posture is upright, and her motor activity and gait are normal. She is well-dressed and exhibits good personal hygiene. No significant body or breath odors are noted. The patient’s facial expression is neutral, and her affect and reactions to people and things are appropriate.

HEENT:

Head: Normocephalic, no signs of trauma or abnormality.

Eyes: Bilateral conjunctival injection noted. Eyelids are not swollen. Pupils are equal, round, and reactive to light. No discharge or crusting was observed.

Ears: Bilateral external ears are normal in appearance. No swelling or tenderness was noted. No cerumen or discharge was observed.

Nose: Pale, boggy nasal mucosa with clear thin secretions. Enlarged nasal turbinates obstruct airway flow. No nasal polyps or septal deviation was observed.

Throat: Mild erythema observed. Tonsils are not enlarged. No exudate or lesions were noted.

Respiratory: Lungs are clear to auscultation bilaterally. No abnormal breath sounds (e.g., wheezes, crackles) were detected. Respiratory effort is normal.

Cardiology: Heart sounds are regular, with no murmurs, gallops, or rubs. Normal rate and rhythm. No peripheral edema was observed.

Lymphatics: No lymphadenopathy was noted in the cervical, axillary, or inguinal regions.

Psychiatric: No apparent signs of psychiatric abnormalities. The patient is cooperative and demonstrates appropriate behavior.

Neurological: No focal neurological deficits observed. Cranial nerves II-XII are intact. No motor or sensory abnormalities were noted. Normal coordination and reflexes.

Diagnostics/Labs:

  1. Allergy testing
  2. Complete blood count
  3. Pulmonary function tests (PFTs)
  4. Chest X-ray
  5. Strep test

ASSESSMENT:

Differential Diagnoses:

  1. Common Cold (Viral Rhinitis)
  2. Non-Allergic Rhinitis
  3. Conjunctivitis
  4. Sinusitis

Primary Diagnosis:

  1. Seasonal rhinitis

The primary diagnosis for the patient’s symptoms is seasonal rhinitis, also known as seasonal allergic rhinitis or hay fever. This diagnosis is supported by the patient’s history of recurrent symptoms in the spring, lasting for six to eight weeks. The patient experiences a runny nose with clear mucus, intermittent sneezing, eye itching, and occasional throat tickling (Akhouri & House, 2022). Physical examination findings, including conjunctival injection, pale and boggy nasal mucosa with clear secretions, and enlarged nasal turbinates, further suggest an allergic etiology. The patient’s family history of seasonal allergies and previous relief with Claritin support this diagnosis.

There are several differential diagnoses to consider for this patient. First, common cold or viral rhinitis could explain the patient’s symptoms of a runny nose and occasional throat tickling. However, the duration of symptoms for nine days and the recurring pattern in the spring make seasonal rhinitis a more likely diagnosis (Pappas, 2019). Non-allergic rhinitis is another possibility, but the patient’s history of symptoms occurring specifically in the spring and the presence of conjunctival injection suggest an allergic component (Ponda et al., 2022). Conjunctivitis is a consideration due to itching in the eyes and conjunctival injection, but the absence of significant eye discharge or swelling, along with the presence of nasal symptoms, makes seasonal rhinitis a more plausible primary diagnosis (Azari & Arabi, 2020). Sinusitis is less likely due to the absence of typical signs such as facial pain, pressure, or fever and the normal respiratory effort observed during the examination.

Several diagnostic tests can be used to confirm the primary diagnosis and differentiate it from other possible illnesses. Allergy testing can help identify specific allergens responsible for seasonal rhinitis symptoms, aiding in developing an appropriate treatment plan (Testera-Montes et al., 2021). A complete blood count (CBC) may be performed to rule out other systemic causes of symptoms, such as infections or inflammatory conditions. Pulmonary function tests (PFTs) could be useful if there is suspicion of underlying asthma or if the patient’s symptoms persist despite appropriate treatment for seasonal rhinitis. Suppose some respiratory symptoms or findings suggest the need to evaluate the lungs for other potential causes, a chest X-ray may be considered.

 

References

Akhouri, S., & House, S. A. (2022, June 5). Allergic rhinitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538186/

Azari, A. A., & Arabi, A. (2020). Conjunctivitis: A systematic review. Journal of Ophthalmic & Vision Research, 15(3), 372–395. https://doi.org/10.18502/jovr.v15i3.7456

Pappas, D. E. (2019). The common cold. National Library of Medicine; Elsevier. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152197/

Ponda, P., Carr, T., Rank, M. A., & Bousquet, J. (2022). Non-allergic, allergic rhinitis, and immunotherapy: Advances in the last decade. The Journal of Allergy and Clinical Immunology: In Practice. https://doi.org/10.1016/j.jaip.2022.09.010

Testera-Montes, A., Jurado, R., Salas, M., Eguiluz-Gracia, I., & Mayorga, C. (2021). Diagnostic tools in allergic rhinitis. Frontiers in Allergy, 2. https://doi.org/10.3389/falgy.2021.721851

 

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