Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Some of the symptoms that affect the nose, throat, head, ears, and eyes include structural abnormalities, injuries, infections, and severe health conditions. Since some of the manifestations that happen in these body parts may be vague, certain diagnostic tests may be used to get accurate and relevant information that may be used to identify the exact health issue. The purpose of this paper is to explore how to evaluate the throat, head, neck, eyes, and ears to develop a diagnosis. The format of the SOAP note will be used for the given case study which involves the signs and symptoms requiring further assessment of the throat.
Focused SOAP Note for Throat Exam
Case Study
The case involves a 32-year -old female identified as Chantal. The patient comes to the office complaining of feeling tired and her hair falling out. In one year, Chantal has gained up to 30 pounds and she states that she has noted a significant decrease in appetite. During the review of the system, she reports that she has not been sleeping well and often feels cold. She patients is still able to enjoy her hobbies and she denies being depressed.
Soap Note for Throat Exam
SUBJECTIVE DATA
Patient’s Initials: C Age: 32 years old Gender: Female
Chief Complaint: “hair fall out” and “feeling tired”
History of Present Illness: Chantal arrives at the clinic with three days of feeling tired and hair falling out. She also complains of increased weight by 30 pounds in one year, but she notes a significant decrease in appetite. The patient also says that she feels cold always, postnasal drainage, nasal congestion, and rhinorrhea. On observation, it is noted that the client uses her fingers to rub and touch the bridge of her nose. The client also confirms that she has been taking over the counter Mucinex at HS to assist her breath with being successful. The throat seems to be mildly erythematous and no enlargement of the throat is seen.
Medications: Mucinex OTC QHS PRN and Lisinopril 20mg PO QD
Past Medical History: NKDA
Past Surgical History: Notable pins in the ankles after an MVA surgery in 2005.
Sexual / Reproductive History: heterosexual, married, two children, sexually active
Immunization History: Pneumonia vaccine in 2015 and flu vaccine in 2016
Family History: Lives with her spouse and her children
ROS:
General: feelings cold always and she abnormal sleeping patterns. She can enjoy all her hobbies and she believes that is she not depressed. She gained approximately 30 pounds in one year.
HEET:
Nose: Clear nasal discharge, nasal congestion, and itchy eyes.
Eyes: Denies changes in vision or hearing other than watery eyes and itchiness. Confirms wearing glasses for farsightedness. No history of photophobia, glaucoma, cataracts, and diplopia.
Mouth: No dental caries noted or halitosis observed. Denies challenges in chewing or swallowing,
Neck: No lymphadenopathy, denies pain, no masses noted
Ears: no drainage, no ear infection, no smell intact
Respiratory: Denies coughing, SOB, clear lungs, and sputum production.
Gastrointestinal: No bowel movements, nausea, constipation, or vomiting.
CV: Denies palpitations and chest pains. No medical history of arrhythmia.
Skin: No lacerations or open wounds, rashes, itching, or bruising.
Psych: Denies anxiety or depression
MS: a history of trauma
Neuro: Denies fall, migraines, and seizures
OBJECTIVE
Physical Exam:
Vital signs: P 76, BP 126/70 R arm, RR 16, Wt. 212# Ht. 5’11, T 97.9 oral
General: Appears fatigued, clean, alert, and oriented
HEENT: Wears glasses to enable her to read, reports a lack of taste and smell. The tonsils appear normal. Denies changes in hearing and vision. The throat is erythematous.
Neck: No abnormalities observed, no abnormal tenderness with palpitation.
Chest: CTA bilaterally
Heart: Normal and regular pulses in the four extremities. No irregular heartbeat that was noted.
Abdomen: Hyperactive bowel sounds in all the four parts, no abnormalities noted.
Rectal: Not evaluated
Skin: dry, pale, warm
Musculoskeletal: No aberrations noted
ASSESSMENT:
Lab tests:
Rapid Strep-Negative
CBC-WNL
Flu Swab-Negative
Differential diagnoses:
- Rhinovirus – The illness is linked with the sore throats, sinus infections, and common cold (Ball, 2015). The symptoms associated with this condition is characterized by congestion, sneezing, running nose, congestion, cough, loss appetite, weakness, fatigue, and muscle aches (Petersen, 2016).
- Acute sinusitis- This is a condition that is caused by an infection in one or all of the paranal sinuses. Some of the common symptoms include loss of smell, nasal obstruction, facial pain, and anterior discharge.
- Chronic sinusitis- This condition is associated with the inflammation of the nasal passages and cavities that last for about 8 weeks with no relief from the treatment. The patient may experience issues breathing since the nose has been obstructed by mucus. The patient may also experience pain and swelling of the eyes causing headaches(Hamilos,2000).
- Allergic rhinitis- The condition arises when the body is exposed to certain allergens as a reaction to the inflammation. The condition is commonly caused by pollen allergens. The symptoms of the condition include sneezing, running nose, watery eyes, and itchy eyes.
PLAN
- Providing education on specific allergens that may cause the symptoms. These allergens may include pollen and mites.
- If the case severe the patient should undergo immunotherapy or see an allergist for further recommendations
- Daily intake of antihistamine that also contain a decongestant. It must not interfere with her HTN or any other medication that she is taking.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination. St. Louis, MO.
Hamilos, D. L. (2000). Chronic sinusitis. Journal of Allergy and Clinical Immunology, 106(2), 213-227.
Petersen, S. W. (2016). Advanced health assessment and diagnostic reasoning. Jones & Bartlett Learning.