Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

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.

Episodic/Focused SOAP Note

Patient Information: R.B., 50 year old Caucasian Male.

Subjective.

CC: “Nasal Congestion and Itching x 5 days”

HPI: R.B. is a 50-year-old white male complaining of nasal congestion, sneezing, rhinorrhea, postnasal drainage, and itchy nose, eyes, palate, and ears for 5 days. The patient reports taking Mucinex OTC to help breathe at night, but relief has been minimal. Denies headache or pain.

Medications: Mucinex OTC 1 tab orally every night.

Allergies: NKDA, reports seasonal allergies.

PMHx: No significant medical history. Denies illnesses or surgeries. Hospitalized in 2002 for back injury following a motor vehicle accident. Up to date on his immunizations, received his flu shot this season.

Soc Hx: Married with 2 children ages 12 and 14. X-smoker, quit in 2006. Drinks alcohol occasionally reports once or twice per month. He has a Bachelor’s degree in business, and runs his own consulting firm. He enjoys surfing and snowboarding with his family. Uses seat belt, and denies using cell phone while driving. He exercises regularly, and eats a heart healthy diet. Sleeps well, but not for the past 5 nights since his symptoms started.

Fam Hx: Both parents alive, father has HTN, well controlled. Mother has breast cancer, S/P mastectomy in 1994, in remission. Has two siblings ages 42 and 46 with no significant illnesses. His two children ages 12 and 14 are healthy. Grandparents deceased, does not recall ages and causes of death.

ROS:

General: AAO X 4, well groomed, denies fever, chills, or fatigue. Appears tired from lack of sleep.

HEENT: Denies headaches. Eyes are itchy and red, PERRLA, no vision changes. Tympanic membranes intact, no changes in hearing, no discharge from ears. Nose is congested, and itchy; nasal mucosa is pale and boggy with thin clear secretions, and nasal turbinates are slightly enlarged. Throat is mildly erythematous, with no enlarged tonsils.

Neck: Trachea is in the midline, no deviation. No swollen lymph nodes.

Skin: No rash or itching. No changes in color or pigmentation. Good skin turgor.

Cardiovascular: No chest pain, pressure, or discomfort. No palpitations. No edema.

Respiratory: No S.O.B. or dyspnea. No cough.

Musculoskeletal: No muscle, back, or joint pain, no stiffness. Denies fatigue.

Lymphatics: No enlarged nodes.

Allergies: Reports seasonal allergies, NKDA.

Objective.

Physical Exam:

General: AAO x 4, denies weakness, denies fatigue, well groomed, well nourished.

V/S: Temp: 98 degrees Fahrenheit, Pulse: 68 beats per minute and regular, Respirations: 14 breaths per minute, BP: 120/80, Weight: 190 lbs.

HEENT: Head is normocephalic. Eyes are itchy and red. Tympanic membranes are intact with no drainage. Nose is congested, and with pale, boggy mucosa, enlarged nasal turbinates and clear thin secretions. Rhinorrhea. Throat is mildly erythematous, no tonsillitis, no ulcers, no purulent discharge, and no bleeding noted.

CV: no chest pain or discomfort, no palpitations, no edema.

Respiratory: No S.O.B., no dyspnea. Lung lobes clear to auscultation with good bilateral air entry. Lung expansion equal and symmetric.

Musculoskeletal: No pain, good range of motion, symmetric and adequate strength.

Lymphatics: No enlarged nodes. No history of splenectomy.

Allergies: Seasonal allergies. No known drug allergies.

Diagnostic Results:

Skin Test: positive to pollen.

Allergic rhinitis can almost always be diagnosed based on history alone (Delves, 2016). Diagnostic testing is not routinely needed unless patients do not improve when treated empirically; for such patients, skin tests are done to identify a reaction to pollens or to dust mite feces, cockroaches, animal dander, mold, or other antigens, which can be used to guide additional treatment (Delves, 2016). According to Nelvis, Binkley, and Kabali, skin testing is accurate in discriminating subjects with or without allergic rhinitis (2016).

Allergen-specific IgE antibody testing [Radioallergosorbent testing (RAST)]: Not done.

This test is particularly useful in primary care if percutaneous testing is not practical or if the patient is taking a medication that interferes with skin testing (Quillen and Feller, 2006).

Differential Diagnosis:

Allergic Rhinitis: Allergic rhinitis is defined as symptoms of sneezing, nasal pruritus, airflow obstruction, and mostly clear nasal discharge caused by IgE-mediated reactions against inhaled allergens and involving mucosal inflammation driven by type 2 helper T cells (Wheatley & Alkis, 2015). This is the most likely Dx based on clinical history and positive skin test.

Non-Allergic Rhinitis: is usually also diagnosed based on history. Lack of a clinical response to treatment for assumed allergic rhinitis and negative results on skin tests and/or an allergen-specific serum IgE test also suggest a non-allergic cause (Delves, 2016). This Dx is likely, but positive skin test confirms allergy to pollen.

Sinusitis: inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea, and facial pain or pressure; sometimes malaise, headache, and/or fever are present (Marvin, 2017). This Dx is unlikely due to the absence of S and Sx of infection.

Common Cold: The common cold is an acute, self-limiting viral infection of the upper respiratory tract involving the nose, sinuses, pharynx and larynx. The virus is spread by hand contact with secretions from an infected person (direct or indirect) or aerosol of the secretions and virus (Allan & Arroll, 2014). This Dx is unlikely as the patient’s symptoms have lasted 5 days, he does not complain of fatigue or malaise, the lack of S and Sx of infection, and due to his complaints of itching.

Tonsillopharyngitis: Also known as sore throat. This is pain in the posterior pharynx that occurs with or without swallowing. Tonsillopharyngitis is predominantly a viral infection; a lesser number of cases are caused by bacteria (Marvin, 2016). This Dx is unlikely due to lack of throat pain, lack of enlarged tonsils, and absence of S and Sx of infection.

Plan: Nasal corticosteroids, or oral antihistamines with decongestants (Marvin,2017).

References

Allan, G. M., & Arroll, B. (2014). Prevention and treatment of the common cold: making sense of the evidence. CMAJ : Canadian Medical Association Journal, 186(3), 190–199. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928210/

Delves, P. J. (2016). Allergic Rhinitis. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/allergic-rhinitis#v6515770

Marvin, P. F. (2016). Sore Throat. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-to-the-patient-with-nasal-and-pharyngeal-symptoms/sore-throat

Marvin, P. F. (2017). Sinusitis. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/nose-and-paranasal-sinus-disorders/sinusitis

Nelvis, F. I., Binkley, K., and Kabali, C. (2016). Diagnostic accuracy of skin-prick testing for allergic rhinitis: a systematic review and meta-analysis. Allergy, Asthma & Clinical Immunolog. 12(20). Retrieved from https://aacijournal.biomedcentral.com/articles/10.1186/s13223-016-0126-0

Quillen, D. M., & Feller, D. B. (2006). Diagnosing Rhinitis: Allergic vs. Nonallergic. American Family Physician, 73(9), 1583-1590. Retrieved from https://www.aafp.org/afp/2006/0501/p1583.html

Wheatley, L. M., & Togias, A. (2015). Allergic Rhinitis. The New England Journal of Medicine, 372(5), 456–463. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324099/