Make a soap note: assessing ear, nose, and throat

Make a SOAP Note: Assessing Ear, Nose, and Throat

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes, but would probably perform a simple strep test.

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: By Day 1 of this week, your instructor will have assigned you to one of the following case studies to review for this Discussion. Also, your 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 1: Nose Focused Exam

Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past two nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.

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.

Case 3: Focused Ear Exam 

Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past two days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.

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.

Note: Before you submit your initial post, replace the subject line (“Week 5 Discussion”) with “Review of Case Study ___,” identifying the number of the case study you were assigned.

Address the following in the SOAP Note:

1.     A description of the health history you would need to collect from the patient in the case study to which you were assigned.

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

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

REFERENCES:

Readings

·         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.

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

This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.

o    Chapter 11, “Eyes” (pp. 204-230)

In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.

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

The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.

·         Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

o    Chapter 15, “Earache” (pp. 174–183)

This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination, as well as how these questions lead to a focused physical examination.

o    Chapter 21, “Hoarseness” (pp. 248-255)

This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient both through questions and through physical exams.

o    Chapter 25, “Nasal Symptoms and Sinus Congestion” (pp.301-309)

In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.

o    Chapter 30, “Red Eye” (pp. 357-368)

The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.

o    Chapter 32, “Sore Throat” (pp. 381-389)

A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.

o    Chapter 38, “Vision Loss” (pp. 446-457)

This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.

·         Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

o    Chapter 5, “SOAP Notes” (pp. 91–118)

Note: Download the seven documents (Adult Examination Checklists and Physical Exam Summaries) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.

·         Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for head, face, and neck. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. 

This Adult Examination Checklist: Guide for Head, Face, and Neck was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

·         Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for eye assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. 

This Adult Examination Checklist: Guide for Eye Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

·         Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for ear assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. 

This Adult Examination Checklist: Guide for Ear Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

·         Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for nose, paranasal sinuses, mouth, oropharynx. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. 

This Adult Examination Checklist: Guide for Nose, Paranasal Sinuses, Mouth, Oropharynx was published as a companion toSeidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

·         Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Ears, nose, and throat. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. 

This Ears, Nose, and Throat Physical Exam Summary was published as a companion to Seidel’s guide to physical examination(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com

·         Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Eyes. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. 

This Eyes Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

·         Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Head, face, and neck. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. 

This Head and Neck Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

·         Browning, S. (2009). Ear, nose, and throat problems. General Practice Update, 2(9), 9–13. 

Retrieved from the Walden Library databases.

This article contains a question and answer session on ear, nose, and throat problems. The article reviews specific topics, such as when to use eardrops and new post-nasal drip treatments, and the referral of persisting cough cases by general practitioners.

·         Lloyd, A., & Pinto, G. L. (2009). Common eye problems. Clinician Reviews, 19(11), 24–29.

Retrieved from the Walden Library databases.

The authors of this article describe different eye problems, their symptoms, and recommended treatments. The authors also emphasize the need to conduct an eye exam and take an ocular history.

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

This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging).

Media

Online media for Seidel’s Guide to Physical Examination

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose, and throat. Refer to Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

Optional Resources

·         LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

o    Chapter 7, “The Head and Neck” (pp. 178–301)

This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck conditions.