NRNP 6540 Week 4 Assignment Week 4: Case Study 1: A 76-year-old woman presents today with complaints of nasal drainage

NRNP 6540 Week 4 Assignment Week 4: Case Study 1: A 76-year-old woman presents today with complaints of nasal drainage Head, Neck, and Face Disorders in the Older Population NRNP 6540F Advanced Practice Care of Older Adults Head, Neck, and Face Disorders in the Older Population Older adults face many age-related disorders that involve the head, neck, ad face. Advanced practice nurses should assess older patients appropriately, as many of these conditions significantly affect their quality of life. The goal of this paper is to discuss a focused subjective, objective, assessment, and plan (SOAP) for a geriatric patient with complaints of upper respiratory tract symptoms. The paper also aims to present diagnostic tests, differential diagnoses, treatment plans, and reflect learnings from analyzing the medical condition affecting the older patient. Focused SOAP Note Subjective Patient Information: Mrs. A, 76, White, Female Chief Complaint: Mrs. A came to the clinic complaining of persistent “runny nose” for 3 weeks now, associated clearing of throat, and nasal congestion on awakening in the morning. History of Present Illness: Mrs. A is a 76-year-old white female who comes to the clinic with complaints of nasal drainage, clearing of throat, and occasional nasal congestion that usually occurs when walking in the morning. The said symptoms usually occur to her during spring, in which she associated the nasal discharge with pollination. Being now in the winter season, the patient could not associate the trigger of her symptoms. Patient also reported she recently moved into an independent living center after residing in her home for 40 years. Current Medications: Medication unknown Allergies: Seasonal allergies Past Medical History: Allergic Rhinitis (AR) Immunization status unknown Unknown last visit to primary doctor Social and Substance History: Recently moved to an independent living center after living in her home for 40 years. Unknown tobacco, alcohol, and drug use. Family History: Family history unknown Surgical History: No surgical history was reported Reproductive Hx: Postmenopausal Review of Systems: The focused review of systems for a patient with upper respiratory symptoms should include general; head, eyes, ears, nose and throat; respiratory; integumentary; and allergy. • General: No fever, chills, weakness, fatigue, and weight loss. • Head: No headache. No trauma reported. • Eyes: No blurred vision, double vision or visual loss. Denies eye pain. • Ears: No loss or changes in hearing, ringing, and discharges. • Nose: Reports persistent “runny nose” for the past three weeks. Reports occasional nasal congestion. • Throat: Reports occasional clearing of throat. No chewing or swallowing difficulties. No changes to voice and taste. • Respiratory: No shortness of breath, cough, hemoptysis. • Integumentary: No changes to skin, hair, and nails. Denies rashes or changes to moles. • Allergic: No history of asthma, hives, eczema. Has history of seasonal AR. Objective Physical exam: General: Awake, alert and oriented to person, place and time. Speech is clear and coherent. Good eye contact. Appears well groomed and well nourished. Vital Signs: BP: 1300/84 mm/Hg, Heart Rate: 78, Respiratory Rate: 20 and unlabored, Temperature: 98.6 degrees Fahrenheit. HEENT: Head: Normocephalic and atraumatic. Intact facial sensation. Eyes: Pupils equal, round, and reactive to light and accommodation. No AV nicking or exudates in fundoscopic exam. No abnormal discharge noted. No periorbital swelling noted. Eye brows symmetrical. Ears: Symmetrical. Patent external auditory canal with no swelling noted. No abnormal ear discharges noted. Tympanic membranes intact with no erythema or effusion. Nose: Symmetrical. Clear nasal discharges noted with mild swelling of the nasal mucosa. No nasal deviation, flaring, or nasal polyps noted. Throat: Patient noted attempts to clear throat occasionally. No erythema or exudates noted. Gag reflex intact. Neck: Supple with full range of motion. Carotid arteries wit no bruits or jugular vein distention. No masses palpated. No tracheal deviation noted. Respiratory: Clear lung sounds in all lung fields to auscultation with inspiration and expiration. Equal chest with rise and fall bilaterally, upon inspiration and expiration. Integumentary: No significant rash or lesions noted. Skin color appropriate for age. Skin warm to touch with skin turgor appropriate for age. No clubbing or cyanosis noted to nails. Lymphatics: No enlarged lymph nodes palpated. Diagnostic tests: 1. Skin testing – The test determines sensitivity to allergens that cause AR. According to Health Quality Ontario (2016), since skin prick testing is easy to implement and less invasive, it is recommended to diagnose AR, then followed by intradermal testing to confirm the skin prick test results. Skin testing is reliable tool to diagnose AR. In a metaanalysis performed by researchers, its sensitivity was 85% and specificity was 77% (Health Quality Ontario (2016). 2. Total serum IgE testing If skin testing cannot be performed due to medications or skin conditions, total serum IgE testing is an alternative. Small et al. (2015) explained that allergen-specific IgE tests provide an in vitro titer of a patient’s specific IgE levels against specific allergens. If the patient in the case study cannot stop the antihistamine or has extensive eczema that prevents skin testing, serum IgE testing can be done. 3. Sinus CT Scan CT scan will confirm the presence of nasal polyp (Stevens et al., 2016). In chronic sinusitis with nasal polyps, the polyps that develop in the bilateral sinonasal cavity are usually benign, but are causing the symptoms. The CT scan will determine the phenotype and any unilateral polyp should concern for a possible malignancy (Stevens et al., 2016). Assessment Differential diagnoses: 1. Allergic Rhinitis A broad definition of rhinitis is an inflammation of the nasal mucosa. AR is the most common classification of chronic rhinitis that affects 10%-20% of the population affecting the quality of life, sleep, and work performance (Small et al., 2018). Traditionally, AR either occurs during specific seasons (seasonal) or throughout the year (perennial). The patient in the case study reports that she usually has symptoms during spring, attributing the symptoms from pollens; hence, the provider can initially classify her AR as seasonal. However, it is already winter; the practitioner can start ruling out seasonal and suspect a perennial type of AR. Classic symptoms of rhinitis include clear, watery nasal discharge, nasal congestion, itching, and sneezing (Kennedy-Malone et al., 2019). Pertinent positives pointing to AR are the patient’s symptoms of nasal drainage, nasal congestion, and clearing of the throat, possibly due to itching or attempt to clear posterior drainage, which is all typical of AR. Exposure to environmental pollutants like dust, animal dander, and indoor or outdoor molds would trigger perennial AR (KennedyMalone et al., 2019). Mrs. A recently moved to an independent living center, and it would be good to identify the possible environmental pollutant that triggered the patient’s symptoms. 2. Viral Upper Respiratory Tract Infection (URI) The common cold is a type of URI, usually caused by a virus that causes inflammation of the nasal passages (Kennedy-Malone et al., 2019). Viral URI is generally self-limiting with minor bodily complaints. Common cold symptoms are typically characterized as nasal congestion and drainage, sneezing, sore throat or scratchy throat, cough, and general malaise (Barrett, 2018). Pertinent positives for Mrs. A include nasal drainage, congestion, and clearing of throat that point to URI as a differential diagnosis. The patient did not report sneezing, cough, and general malaise; however, Barrett (2018) explained that cough might be present in URI, but it tends to appear late in the disease and usually lasts for weeks after other symptoms have resolved. 3. Acute Sinusitis Acute rhinosinusitis (also called sinusitis) is defined as the temporary inflammation of the mucosal lining of the paranasal sinuses occurring less than four weeks (Ah-See, 2015). Typical clinical presentation are nasal congestion, rhinorrhea, facial pain, sneezing, facial pain, and malaise with fever in severe conditions (Ah-See, 2015). Again, pertinent positives for Mrs. A are her rhinorrhea and nasal congestion in addition to the duration that is less than four weeks. Sneezing, malaise, and fever were not reported, but the provider should keep in mind that bodily weakness and fever are usual symptoms when the disease condition is severe. A pertinent negative for the patient is the absence of facial pain, which is very typical for acute sinusitis; hence, this can be ruled out. 4. Chronic rhinosinusitis with nasal polyps (CRSwNP) CRSwNP is a condition where there is both subjective and objective evidence of chronic sinonasal inflammation with symptoms such as anterior or posterior rhinorrhea, nasal congestion, hyposmia, and facial pressure lasting for more than 12 weeks (Stevens et al., 2016). The patient in the case study reported subjective symptoms of congestion and both anterior and posterior rhinorrhea. The absence of hyposmia and facial pain are the pertinent negatives. There is a need for the clinician to obtain more information during their physical assessment to confirm the diagnosis. If the symptoms continue to present for more than 12 weeks, this can increase suspicion of the presence of CRSwNP. Plan 1. Treatment Pharmacological therapy for AR is aimed to manage the patient’s symptoms. According to Kennedy-Malone et al. (2019), intranasal corticosteroid nasal sprays are highly effective in treating AR as it prevents early and late-stage responses. The advanced practice nurse may prescribe the patient intranasal corticosteroids like Fluticasone furoate (Veramyst), two sprays each nostril once daily, or Fluticasone propionate (Flonase), two sprays each nostril once daily or one spray each nostril twice daily. Intranasal corticosteroids can be started with oral antihistamines (KennedyMalone et al., 2019). Avoiding the use of first-generation antihistamines (diphenhydramine) is recommended, though, because of its sedative effect. The Beers criteria do not recommend giving first-generation antihistamines due to its sedating and anticholinergic properties, promoting delirium, falls, urinary retention, dry mouth, and constipation (DeRhodes, 2019). First-generation antihistamines may also worsen certain conditions that are typical in older patients, such as bladder neck obstruction, narrowangle glaucoma, and benign prostatic hypertrophy (Kennedy-Malone et al., 2019). For the said reasons, it is best to give oral second-generation antihistamines. Seidman et al. (2015) discussed that oral second-generation antihistamines are effective given alone to treat sneezing and itching in AR or in combination with intranasal steroid sprays. The practitioner can prescribe Loratadine (Claritin) 10 mg once daily; however, if the patient has liver or renal insufficiency, it should be taken every other day. Drug interactions should be taken into consideration when prescribing to older patients. The secondgeneration antihistamines can cause dysrhythmias when combined with antifungals, macrolides, tricyclic antidepressants, and class Ia antiarrhythmic medications (KennedyMalone et al., 2019). 2. Education It is essential for the patient to identify the environmental triggers of her symptoms. Once identified, she needs to avoid them and try to control environmental factors. Control of seasonal pollens can be done by keeping windows closed and keeping the aircondition on during seasons of high pollen counts. Mold exposure outdoors can be controlled by wearing masks when outdoors. The prescribed intranasal corticosteroids and antihistamines should be taken regularly for symptom control. Having to wait when the symptoms are severe before using the prescribed medications may result in the medications’ lack of efficacy.