Head, Neck and Face Case Study| Answered

A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally, the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.

Chief complaint: Persistent “runny nose” for the 3-week duration, associated clearing of the throat and nasal congestion on awakening in the morning.

Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20.

What further ROS questions will you want to ask her? List at least three.

What physical exam (PE) will you perform on this patient? List at least three.

What are the differential diagnoses that you are considering? Describe at least four.

What laboratory tests will help you rule out some of the differential diagnoses?

You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR).

Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient?

List at least two treatment options: medications with dose, side effects, and/or cautions in the older adult.

When will you have the patient follow-up? Be specific.

NOTE: Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP noteBe creative, but do not deviate from the main points of the case study.

 Answer

Focused SOAP Note Template

 

Patient Information:

S.T., 76-Year-old Hispanic female

S (subjective)

CC (chief complaint): The client presents to the clinic with persistent nasal drainage that has been there for three weeks, associated with clearing the throat and occasional nasal congestion in the morning.

HPI (history of present illness): 76-year-old Hispanic female has been having a runny nose for the last three weeks. The runny nose has been accompanied by nasal congestion upon waking up in the morning and clearing the throat.

Current Medications: multivitamins once a day- used to boost immunity.

Allergies: Allergic to pollen and dust. Responds with a runny nose. No known food and drug allergies. Pollen allergy is an environmental allergy triggered by pollen and mainly occurring at different times of the year. Individuals respond through a runny nose, sneezing, coughing, and itchy and watery eyes. Dust allergy is also an environmental allergy triggered by dust and occurring throughout the year.

PMHx: All immunizations are up to date. Has no major illnesses. No major surgery done in the past. Was hospitalized at 16 due to community-acquired pneumonia.

Soc and Substance Hx: S.T. is a retired music teacher. Her husband died four years ago. She has two daughters who visit her often and who are her greatest support system. She teaches piano lessons at her home, where she lives alone. She has no history of using tobacco. Her house has working smoke detectors, and she uses seatbelts at all times to promote safety.

Fam Hx: Both parents are deceased. The mother was hypertensive. Her brother-69 is diabetic. One of her daughters is asthmatic. The other daughter is healthy. All four grandchildren are healthy. No family history of other major illnesses.

Surgical Hx: no history of major surgical procedures.

Mental Hx: Has not been diagnosed or treated with any mental illness. No concerns of anxiety and depression. Has no history of self-harm practices, suicidal or homicidal ideations.

Violence Hx: has no history of personal, home, or community concern or issues of violence compromising her safety.

Reproductive Hx: Her last menstrual period menstrual period was at 45 years. She is heterosexual. Used hormonal contraceptives. Has no sexual concerns.

ROS

  • General: denies unexplainable loss of weight, fever, and chills. Denies general weakness and fatigue.
  • Head: Reports occasional headaches due to sinus pressure and nasal congestion. Denies facial pain and discomfort.
  • EENT: Eyes-denies visual loss, blurred vision, or double vision. Reports occasional itchy and watery eyes. Reports no yellow sclerae. Ears – reports no hearing loss. Denies ear pain. Nose – reports occasional sneezing and nasal congestion. Reports a runny nose. Throat – reports a sore throat that has been there for three weeks.
  • Skin: denies any skin rash. Reports no itching
  • Respiratory: denies shortness of breath and reports coughing and sneezing occasionally. No sputum.
  • Cardiovascular: denies chest pain, pressure or discomfort. No edema or palpitations.
  • Lymphatic: no enlarged nodes. Reports no history of splenectomy.
  • Allergies: allergic to dust and pollen. No history of asthma or hives.

O (objective)

Physical exam:

Vital Signs: Temperature: 96.8 BP:130/84 Pulse:78 RR 20 Weight:74kg Height:5’4 BMI:27.5

General: client A&O. appears relaxed, with no apparent distress.

HEENT: Head normocephalic, no masses, normal scalp hair distribution. PERRLA bilaterally, EOMI. Eyelids conjunctiva pink, no lesions, white sclera. Dark circles noted under the eyes. Eyes are teary. TM intact and pearly gray. Oral mucosa moist, no lesions. No sinus tenderness, but appears red. Full ROM without clicks. No lymphadenopathy. Thyroid smooth.

Respiratory: No ribcage or chest tenderness, deformities or masses. The apex and peripheral pulse rate are 78 beats per minute. S1 and S2 with no murmurs. Capillary refill of <2 seconds

Cardiovascular: Symmetrical chest movement with breathing. Vesicular breath sounds auscultated. No crackles or wheezes auscultated. Resonant sound to percussion.

Diagnostic results: The diagnostic tests that were taken include a nasal endoscopy, sinus CT scan, and a nasal swab for Eosinophils. Akhouri and House (2023) note that a nasal endoscopy is a vital diagnostic test when a patient is suspected of having rhinitis since it reveals any signs of inflammation, nasal polyps, and other structural abnormalities. The sinus CT scan is used when the patient is suspected of having other rhinitis-related complications. According to Eguiluz-Gracia et al. (2019), a nasal swab helps confirm the diagnosis of allergic rhinitis. The diagnostic results were increased nasal secretions, milled sinus inflammation, and postnasal drip.

A (assessment)

Differential diagnoses:

  1. Allergic Rhinitis. The primary diagnosis is Allergic rhinitis. According to Akhouri and House (2023), allergic rhinitis is an atopic condition mainly characterized by nasal congestion and nasal pruritis. The condition is usually triggered by allergens. The condition was identified as the primary diagnosis following the diagnostic results support. In addition, the patient in this case presents with nasal congestion, postnasal drip, and throat clearing, which are all symptoms of allergic rhinitis.
  2. Non-allergic rhinitis. Non-allergic rhinitis is a rhinitis type that is not associated with allergens. Guseva and Derbeneva (2020) note that bacterial infections mainly cause non-allergic rhinitis but have symptoms similar to allergic rhinitis. The condition was included in the differential since the patient presents with nasal congestion and rhinorrhea. However, the condition is ruled out because the patient does not present with an itchy nose, which is a major symptom of the condition.
  3. Sinusitis. The condition is mainly characterized by sneezing, nasal discharge, fever, cough, chills, and nasal obstruction (Battisti et al., 2023). The condition was included as a differential diagnosis since the patient, in this case, presents with most of its major symptoms. However, it was ruled out due to a lack of facial pain.
  4. Gastroesophageal Reflux Disease (GERD). GERD is the other differential diagnosis, characterized by chronic cough, throat clearing, and postnasal drip. The patient in this case study presents with throat clearing and postnasal drip, thus a differential. However, the condition was ruled out because it is caused by acid reflux irritating the throat, and the patient, in this case, does not have a chronic cough.

P (plan)

Treatment options for allergic rhinitis include pharmacological therapy using antihistamines and intranasal steroids and immunotherapy (Akhouri & House, 2023). The appropriate medication for this patient is cetirizine 10mg oral tablets once daily. According to Kawauchi et al. (2019), cetirizine is a second-generation antihistamine that is recommended for older adults with allergic rhinitis. One of the side effects of cetirizine is drowsiness, especially in high dosages. Therefore, I will encourage the patient to avoid overdose, thus avoiding the side effects. The recommended patient follow-up for this patient is after four weeks. The follow-up will check the patient’s progress and determine whether changes should be made to the medication or the dosage adjusted.

Furthermore, patient education for a patient with allergic rhinitis is vital. According to Steven (2020), allergic rhinitis patients need to understand the symptoms, their management, lifestyle modifications for triggers and allergens avoidance, and medication adherence. Similarly, in this case, the patient will be educated on the condition’s symptoms, management, and lifestyle modifications. In addition, the essence of follow-up will be emphasized. Being an elderly patient, the nurse will also provide education on home safety and the necessary immunizations for patients in this age population. Interacting with this case study has helped me demystify the different conditions with almost similar symptoms. I learned the importance of using diagnostic results in making the diagnosis. Patient education is also vital in providing holistic care.

References

Akhouri, S. & House, S. A. (2023). Allergic Rhinitis. In: StatPearls [Internet]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK538186/

Battisti, A.S., Modi, P. & Pangia, J. (2023). Sinusitis. [Updated 2023 Mar 2]. In: StatPearls [Internet]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK470383/

Eguiluz-Gracia, I., Pérez-Sánchez, N., Bogas, G., Campo, P., & Rondón, C. (2019). How to Diagnose and Treat Local Allergic Rhinitis: A Challenge for Clinicians. Journal of Clinical Medicine8(7), 1062. https://doi.org/10.3390/jcm8071062

Guseva, A., & Derbeneva, M. (2020). Rhinitis: Differential diagnosis and treatment principles. https://doi.org/10.21518/2079-701X-2020-16-102-108

Kawauchi, H., Yanai, K., Wang, D. Y., Itahashi, K., & Okubo, K. (2019). Antihistamines for Allergic Rhinitis Treatment from the Viewpoint of Nonsedative Properties. International Journal of Molecular Sciences20(1), 213. https://doi.org/10.3390/ijms20010213

Steven G. C. (2020). Shared decision making in allergic rhinitis: An approach to the patient. Annals of Allergy, Asthma & Immunology: Official Publication of the American College of Allergy, Asthma, & Immunology125(3), 268–272. https://doi.org/10.1016/j.anai.2020.06.032

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