ACTUAL
NURS6512 Assignment 1: Case Study Assignment: Assessing the Head,
Eyes, Ears, Nose, and Throat – Episodic/Focused SOAP Note Example
Patient Information:
CL, 28, Female, White American
S.
CC: Runny nose, itchy eyes, itchy throat, fullness of ears, and sneezing
HPI: Mrs C.L., a 28-year-old female, came to the hospital and was well until nine days ago when she developed a runny
nose, itchy eyes, and her ears felt full. The nasal drainage is clear mucus, and she sneezes all day. The patient reports that
the symptoms are seasonal and last about six to eight weeks every spring. She also sneezes all day, her eyes have severe
itch, and her throat is usually itchy during these attacks. The ears also pop sometimes, which is quite uncomfortable. The
symptoms are often self-limiting, do disappear without intervention, and are recurrent during spring, and she decided to
seek treatment this time. The patient claims that colds during the morning and evenings worsen the symptoms.
Chlorpheniramine taken provides temporary symptom relief.
Current Medications:
Chlorpheniramine 12mg twice daily for two days
Green tea 300ml twice daily
Vitamin C supplement 50 ml daily
Allergies: She is allergic to dust and cold and develops a runny nose, nasal congestion, and sneezes. Allergic to penicillin
and develops itchiness and hives. No other known drug or food allergies
PMHx: Diagnosed with severe pneumonia in 8th grade and was admitted for treatment for a week. No surgery or
intubation history was performed during the admission. Diagnosed with nephritis five years ago and was admitted for four
days during the treatment period. She denies a history of surgery or blood transfusion. Childhood immunizations are up to
date. The last tetanus dose was two years ago. Covid-19 vaccine booster was given one year ago. Last flu vaccine seven
years ago she was in college.
Soc Hx: Mrs C. L. is a teacher who teaches fourth-grade students at a local school. She loves playing with the children and
doubles up as the hockey coach in the school. She also loves bible study and fellowship services. She is married with one
3-year-old child. She lives with her husband and child, with whom they have a good relationship. She denies smoking or
alcohol use. She reports using seatbelts when driving, denies participating in extreme sports, and has safety measures at
home, such as smoke detectors and a home phone for emergency calls.
Fam Hx: Her paternal grandparents died in a road accident. Her maternal grandfather is an alcoholic, hypertensive, and
was recently diagnosed with BPH. Her maternal grandmother is asthmatic. Her maternal uncle is asthmatic. She has three
brothers. The eldest brother, Tim, is obese and hypertensive. The other siblings are alive and well
ROS:
GENERAL: Patient denies weight loss, malaise, fever, or fatigue.
HEENT: Eyes: Reports eye itchiness and denies eye discharge or changes in vision acuity. Ears: Reports popping and
fullness of ears. Denies pain, discharge or hearing acuity changes. Nose: Reports a runny nose with clear discharge and
occasional sneezing. Throat: Reports an occasionally itchy throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, pressure, discomfort, palpitations, or edema.
RESPIRATORY: Reports mild difficulty in breathing due to nasal congestion. Denies cough or sputum production.
GASTROINTESTINAL: Denies nausea or vomiting, diarrhea, blood in stool, or diarrhea.
GENITOURINARY: Denies urine retention, burning on urination, urine odor or color change, or lower abdominal pain. LMP:
12/18/2023
,NEUROLOGICAL: Reports mild headache and denies dizziness, numbness or tingling sensation in limbs. Reports
adequate bowel and bladder control.
,MUSCULOSKELETAL: Denies muscle, pain, or joint injury, stiffness, pain
HEMATOLOGIC: Denies easy bruising or uncontrollable bleeding
LYMPHATICS: Denies lymph node enlargement or history of splenectomy.
PSYCHIATRIC: Denies depression or anxiety
ENDOCRINOLOGIC: Denies profuse sweating, cold or heat intolerance, polyuria, polyphagia, or polyuria.
ALLERGIES: Reports runny nose, nasal congestion, and sneezing on exposure to dust. Reports hives and skin rashes on
exposure to penicillin.
O.
Physical exam:
HEENT: Head: Normocephalic, hair evenly distributed, no receding hairline, scalp moist and shiny. Eyes: Erythematous
and teary. Ears: No drainage, pain or changes in hearing acuity. Nose: Clear, thin nasal discharge, nasal mucosa boggy,
enlarged nasal turbinates, obstructed airway. Throat: Mildly erythematous
Neck: No enlarged lymph nodes, trachea midline, and tonsils non-palpable
Chest: symmetrical rising with breathing in and out. No accessory muscle use in breathing., no rashes or lesions. Lungs
clear to auscultation, no crackles or wheezes. Apical pulse 74bpm, S1 and S2 auscultated. No murmurs or gallops
Abdomen: Globular in shape, well hydrated, no scars, lesions or rashes. No organomegaly. Moderate bowel sounds in all
abdomen quadrants. No tenderness on light and deep palpation.
Neurological: All cranial nerves intact. Good plantar and knee-jerk reflexes. Good muscle tone on all extremities.
Vitals
Temp: 37.1oC, Blood pressure 132/77, Pulse Rate- 74, RR- 19, SpO2 94%
Diagnostic results:
The strep test is an ideal test for this patient. The strep test is a simple procedure that will help rule out or confirm
streptococci infection (Ball et al., 2023). Nasal allergen challenge is a test that can be used to identify the offending
allergens and help differentiate between allergic and non-allergic conditions, as Eguiluz-Gracia et al. (2019) support.
A.
Differential Diagnoses
Seasonal Allergic Rhinitis: Allergic rhinitis, a condition caused by a reaction to environmental allergens, is the most
presumptive diagnosis; the duration of illness, history of allergic attacks, and recurrence of the condition in early spring
support the diagnosis. Unlike most upper respiratory tract infections, allergic rhinitis can persist long without management
and easily recur. Allergic rhinitis symptoms include a runny nose, nasal stuffiness, itchy nose, watery and itchy eyes,
headache, coughing, and an itchy palate, coinciding with the patient’s symptoms (Eguiluz-Gracia et al., 2019).
Non-Allergic Rhinitis: In non-allergic rhinitis, the nasal mucosa is inflamed by not from an allergen cause. The symptoms
include nasal congestion, sneezing, runny nose, and a post-nasal drip. A post-nasal drip can precipitate a cough or sore
throat. Eguiluz-Gracia et al. (2019) note that non-allergic rhinitis is often chronic and not seasonal. Non-allergic rhinitis
causes are unknown and primarily affects individuals above 20 years. Non-allergic rhinitis is often challenging to manage
because it lacks a cause and thus can persist for longer than most upper respiratory tract infections (Patel et al., 2020)
Acute nasopharyngitis (Common Cold). The condition is a self-limiting infection lasting 7-10 days. However, a cough
that follows untreated cases may last up to four weeks. Common cold often occurs in the colder seasons, and
transmissions are higher in winter. Common cold presents with symptoms of nasal stuffiness, cough, mild headache,
malaise, fever, sore throat and a runny nose, as Jaume et al. (2020) state. However, common cold symptoms do not last
beyond ten days, ruling it out as the primary diagnosis.
Seasonal Hemophilus Influenza (Flu). Hemophilus influenza is a viral whose symptoms last 3-7 days and are severe,
warranting medical treatment. Uyeki et al. (2019) note that flu symptoms develop rapidly and are often severe, especially in
, children, making it difficult to persevere without seeking treatment. An individual can contract the flu anytime, but seasonal
transmission is often high in the fall. However, Mrs C.L. has had her symptoms for about nine days. She also reports that
NURS6512 Assignment 1: Case Study Assignment: Assessing the Head,
Eyes, Ears, Nose, and Throat – Episodic/Focused SOAP Note Example
Patient Information:
CL, 28, Female, White American
S.
CC: Runny nose, itchy eyes, itchy throat, fullness of ears, and sneezing
HPI: Mrs C.L., a 28-year-old female, came to the hospital and was well until nine days ago when she developed a runny
nose, itchy eyes, and her ears felt full. The nasal drainage is clear mucus, and she sneezes all day. The patient reports that
the symptoms are seasonal and last about six to eight weeks every spring. She also sneezes all day, her eyes have severe
itch, and her throat is usually itchy during these attacks. The ears also pop sometimes, which is quite uncomfortable. The
symptoms are often self-limiting, do disappear without intervention, and are recurrent during spring, and she decided to
seek treatment this time. The patient claims that colds during the morning and evenings worsen the symptoms.
Chlorpheniramine taken provides temporary symptom relief.
Current Medications:
Chlorpheniramine 12mg twice daily for two days
Green tea 300ml twice daily
Vitamin C supplement 50 ml daily
Allergies: She is allergic to dust and cold and develops a runny nose, nasal congestion, and sneezes. Allergic to penicillin
and develops itchiness and hives. No other known drug or food allergies
PMHx: Diagnosed with severe pneumonia in 8th grade and was admitted for treatment for a week. No surgery or
intubation history was performed during the admission. Diagnosed with nephritis five years ago and was admitted for four
days during the treatment period. She denies a history of surgery or blood transfusion. Childhood immunizations are up to
date. The last tetanus dose was two years ago. Covid-19 vaccine booster was given one year ago. Last flu vaccine seven
years ago she was in college.
Soc Hx: Mrs C. L. is a teacher who teaches fourth-grade students at a local school. She loves playing with the children and
doubles up as the hockey coach in the school. She also loves bible study and fellowship services. She is married with one
3-year-old child. She lives with her husband and child, with whom they have a good relationship. She denies smoking or
alcohol use. She reports using seatbelts when driving, denies participating in extreme sports, and has safety measures at
home, such as smoke detectors and a home phone for emergency calls.
Fam Hx: Her paternal grandparents died in a road accident. Her maternal grandfather is an alcoholic, hypertensive, and
was recently diagnosed with BPH. Her maternal grandmother is asthmatic. Her maternal uncle is asthmatic. She has three
brothers. The eldest brother, Tim, is obese and hypertensive. The other siblings are alive and well
ROS:
GENERAL: Patient denies weight loss, malaise, fever, or fatigue.
HEENT: Eyes: Reports eye itchiness and denies eye discharge or changes in vision acuity. Ears: Reports popping and
fullness of ears. Denies pain, discharge or hearing acuity changes. Nose: Reports a runny nose with clear discharge and
occasional sneezing. Throat: Reports an occasionally itchy throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, pressure, discomfort, palpitations, or edema.
RESPIRATORY: Reports mild difficulty in breathing due to nasal congestion. Denies cough or sputum production.
GASTROINTESTINAL: Denies nausea or vomiting, diarrhea, blood in stool, or diarrhea.
GENITOURINARY: Denies urine retention, burning on urination, urine odor or color change, or lower abdominal pain. LMP:
12/18/2023
,NEUROLOGICAL: Reports mild headache and denies dizziness, numbness or tingling sensation in limbs. Reports
adequate bowel and bladder control.
,MUSCULOSKELETAL: Denies muscle, pain, or joint injury, stiffness, pain
HEMATOLOGIC: Denies easy bruising or uncontrollable bleeding
LYMPHATICS: Denies lymph node enlargement or history of splenectomy.
PSYCHIATRIC: Denies depression or anxiety
ENDOCRINOLOGIC: Denies profuse sweating, cold or heat intolerance, polyuria, polyphagia, or polyuria.
ALLERGIES: Reports runny nose, nasal congestion, and sneezing on exposure to dust. Reports hives and skin rashes on
exposure to penicillin.
O.
Physical exam:
HEENT: Head: Normocephalic, hair evenly distributed, no receding hairline, scalp moist and shiny. Eyes: Erythematous
and teary. Ears: No drainage, pain or changes in hearing acuity. Nose: Clear, thin nasal discharge, nasal mucosa boggy,
enlarged nasal turbinates, obstructed airway. Throat: Mildly erythematous
Neck: No enlarged lymph nodes, trachea midline, and tonsils non-palpable
Chest: symmetrical rising with breathing in and out. No accessory muscle use in breathing., no rashes or lesions. Lungs
clear to auscultation, no crackles or wheezes. Apical pulse 74bpm, S1 and S2 auscultated. No murmurs or gallops
Abdomen: Globular in shape, well hydrated, no scars, lesions or rashes. No organomegaly. Moderate bowel sounds in all
abdomen quadrants. No tenderness on light and deep palpation.
Neurological: All cranial nerves intact. Good plantar and knee-jerk reflexes. Good muscle tone on all extremities.
Vitals
Temp: 37.1oC, Blood pressure 132/77, Pulse Rate- 74, RR- 19, SpO2 94%
Diagnostic results:
The strep test is an ideal test for this patient. The strep test is a simple procedure that will help rule out or confirm
streptococci infection (Ball et al., 2023). Nasal allergen challenge is a test that can be used to identify the offending
allergens and help differentiate between allergic and non-allergic conditions, as Eguiluz-Gracia et al. (2019) support.
A.
Differential Diagnoses
Seasonal Allergic Rhinitis: Allergic rhinitis, a condition caused by a reaction to environmental allergens, is the most
presumptive diagnosis; the duration of illness, history of allergic attacks, and recurrence of the condition in early spring
support the diagnosis. Unlike most upper respiratory tract infections, allergic rhinitis can persist long without management
and easily recur. Allergic rhinitis symptoms include a runny nose, nasal stuffiness, itchy nose, watery and itchy eyes,
headache, coughing, and an itchy palate, coinciding with the patient’s symptoms (Eguiluz-Gracia et al., 2019).
Non-Allergic Rhinitis: In non-allergic rhinitis, the nasal mucosa is inflamed by not from an allergen cause. The symptoms
include nasal congestion, sneezing, runny nose, and a post-nasal drip. A post-nasal drip can precipitate a cough or sore
throat. Eguiluz-Gracia et al. (2019) note that non-allergic rhinitis is often chronic and not seasonal. Non-allergic rhinitis
causes are unknown and primarily affects individuals above 20 years. Non-allergic rhinitis is often challenging to manage
because it lacks a cause and thus can persist for longer than most upper respiratory tract infections (Patel et al., 2020)
Acute nasopharyngitis (Common Cold). The condition is a self-limiting infection lasting 7-10 days. However, a cough
that follows untreated cases may last up to four weeks. Common cold often occurs in the colder seasons, and
transmissions are higher in winter. Common cold presents with symptoms of nasal stuffiness, cough, mild headache,
malaise, fever, sore throat and a runny nose, as Jaume et al. (2020) state. However, common cold symptoms do not last
beyond ten days, ruling it out as the primary diagnosis.
Seasonal Hemophilus Influenza (Flu). Hemophilus influenza is a viral whose symptoms last 3-7 days and are severe,
warranting medical treatment. Uyeki et al. (2019) note that flu symptoms develop rapidly and are often severe, especially in
, children, making it difficult to persevere without seeking treatment. An individual can contract the flu anytime, but seasonal
transmission is often high in the fall. However, Mrs C.L. has had her symptoms for about nine days. She also reports that
