Case 2: Focused Throat Exam

Review of Case Study2:

 

In this Discussion, 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.

 

 

 

Note: Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

 

Case 2: 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 over the past two weeks, Lily figured she shouldn’t take her three-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 a slight hoarseness in her voice but doesn’t sound congested.

 

 

 

To prepare:

 

With regard to 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 10 possible conditions that may be considered in a differential diagnosis for the patient.

 

Post  2 page discussion SOAP NOTE on:  a description of the health history you would need to collect from the patient in the case study to which you were assigned.

 

Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

 

List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

 

REFERENCE

 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

 

◦Chapter 10, “Head and Neck” (pp. 184-203)

 

Chapter 12, “Ears, Nose, and Throat” (pp. 231-259)

 

Chapter 21, “Hoarseness” (pp. 248-256

 

 

 

Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html

 

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical. ◦Chapter 7, “The Head and Neck” (pp. 178–301)

Comprehensive SOAP Exemplar

 

Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.

 

Patient Initials: _______ Age: _______ Gender: _______

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): Coughing up phlegm and fever

 

History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.

 

Medications:

1.) Lisinopril 10mg daily

2.) Combivent 2 puffs every 6 hours as needed

3.) Serovent daily

4.) Salmeterol daily

5.) Over-the-counter Ibuprofen 200mg -2 PO as needed

6.) Over-the-counter Benefiber

7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

 

Allergies:

Sulfa drugs – rash

 

Past Medical History (PMH):

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.

2.) Hypertension – well controlled

3.) Gastroesophageal reflux (GERD) – quiet, on no medication

4.) Osteopenia

5.) Allergic rhinitis

 

Past Surgical History (PSH):

1.) Cholecystectomy 1994

2.) Total abdominal hysterectomy (TAH) 1998

 

Sexual/Reproductive History:

Heterosexual

G1P1A0

Non-menstruating – TAH 1998

 

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

 

Immunization History:

Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

 

Significant Family History:

Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.

 

Lifestyle:

She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.

 

She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.

 

Review of Systems:

 

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance

 

HEENT: No changes in vision or hearing; she does wear glasses, and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has a history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

 

Neck: No pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

 

Breasts: No reports of breast changes. No history of lesions, masses, or rashes. No history of abnormal mammograms.

 

Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

 

CV: No chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

 

GI: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

 

GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband.

 

MS: She has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

 

Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. She denied suicidal/homicidal history.

 

Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

 

Integument/Heme/Lymph: No rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties, or history of transfusions.

 

Endocrine: No endocrine symptoms or hormone therapies.

 

Allergic/Immunologic: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

 

 

OBJECTIVE DATA

 

Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

Musculoskeletal: symmetric muscle development – some age-related atrophy; muscle strengths 5/5 all groups

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

 

ASSESSMENT:

 

Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

 

Diagnostics:

Lab:

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

 

Differential Diagnosis (DDx):

1.) Acute Bronchitis

2.) Pulmonary Embolis

3.) Lung Cancer

 

Diagnoses/Client Problems:

 

1.) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40-pack-a-year history

4.) Allergy to sulfa drugs – rash

5.) GERD – quiet, on no current medication

 

PLAN: [This section is not required for the assignments in this course but will be required for future courses.]

 

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