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

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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.

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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-palp