Answer

Episodic /focused SOAP

Patient Information

Age: 50 years old

Race: Caucasian 

Sex: Male

S.

Chief Complain (cc)

Nasal Complications

The RF presented was five days old that included postnasal drainage, sneezing, nasal congestion, and rhinorrhea. The symptoms observed and narrated included itching nose, ears, eyes, and plates. Upon examination, the throat was mildly erythematous. Other observable symptoms include enlarged nasal turbinate, boggy nasal mucosa bearing clear secretion.

HPI

Location: head

Onset: five days

Character: itching nose, nasal congestion, rhinorrhea, boggy nasal mucosa

Timing: Exposed to sun while working as landscape manager

Severity: 7/10

Current Medications

Excedrin for migraine (2PO as needed for headache)

Multivitamins on daily PO

Vitamin D (daily PO)

Maximum strength sinux associated with severe congestion relief and a running nose. The dosage is two caplets in every four hours.

Allergies

No allergies for drugs

Sneezing and running nose, possible allergy for pollens.

PMHx

Immunization up to date

The last date for tetanus immunization was 2012

Soc Hx

Landscape manager

Likes reading and Swimming

Fam Hx

According to the family medical history, the father of the deceased died of cancer at age 65. On the other hand, the mother has a history of hypertension, migraine, and allergies. However, the patient denies involving in any other medical conditions that could be important in understanding his current situation.

The Review of System (ROS)

General the patient was negative for chills and fatigue

No weight loss recorded

HEENT

Head

 All major organs of the head are in normal condition and do not experience significant abnormalities. The patient experienced non-traumatic tenderness. 

Mild auxiliary tenderness in the sinuses

The eyes had bilateral white clear with pink conjunctiva. There was no greenish pigmentation of the skin and the eyes were not white. Nonetheless, the eyes were water with no evidence of periorbital edema.

Bilaterally, the ears had clean canals. The left tympanic membrane was pearly grey 

The nose showed signs of palpated mild sinus. Swelling and nasal turbinate observed.

Mouth/Throat

The mucus membranes are moist

Clear oropharynx without exudates and mild erythema

Neck

The neck had no evidence of thyromegaly

No signs of bruits

Skin

Warm and intact skin with no rashes and lesions, the patient denies incidences of itches.

Chest/Lungs

The expansion of the chest is symmetrical

Lungs demonstrate clarity in auscultation and percussion in bilateral manner. There is no chest pain registered.

Respiratory

Effective and normal breathing, slight cough, and difficulty in breathing reported. No sputum existence indicated.

Gastrointestinal

Active bowel sounds, and no signs of diarrhea or nausea

Abdominal soft

Musculoskeletal

The patient demonstrates normal gait and station

No signs of misalignment

Intact range of motion and asymmetry

Psychiatric

 Normal mood

Good judgment, memory, and insight

Diagnostic Tests

O

Physical Exam

The symptoms observed and narrated included itching nose, ears, eyes, and plates

 Enlarged nasal turbinate, boggy nasal mucosa bearing clear secretion

Diognistic Results

Chest x-rays show no acute processes

A three-year sinus series indicated inflammation and mucosal thickening of the sinuses

CT-scan results ruled out acute sinusitis and other pathologies

A

Differential Diagnosis

Allergic Rhinitis

RF presented symptoms that can be associated with the presence of allergic rhinitis. The symptoms included itching, sneezing, postnasal, anosmia, headache, red eyes, earache, tearing, and rhinorrhea(Scadding, Kariyawasam, Scadding, Mirakian, Buckley, Dixon & Clark, 2017). Most patients with allergic rhinitis develop symptoms while in their early 20s. However, its onset can occur well into adulthood(Sheikh, 2018). The elevation of eosinophil supports the diagnosis of allergic rhinitis. Serum, eosinophil among other clinical factors can be used in conducting diagnosis. A close examination of the neck with a focus on the nasal cavity provides evidence that can be used to understand the underlying disease process.

Acute Sinusitis

Three significant signs are primary diagnosis indicators for acute sinusitis. The symptoms included congestion of the nasal cavity anterior and posterior purulent rhinorrhea, and facial pressure. RF showed that sinus series imaging indicated mucosal sinus thickening. According to RS sub-classifications, the simplest differentiation is determined by the duration of symptoms(Mulvey, Kiell, Rizzi & Buzi, 2019). Laboratory tests such as creative C-protein level, sedimentation rate, and white blood cell counts are used in the diagnosis of acute sinusitis. However, the tests should be supplemented with other clinical findings to ensure accuracy.

Charlotte Chronic

This is a disorder infection interfering with open spaces such as cavities, especially in the skull region around the nose. Common cold virus causes the condition. The sinuses as well as tubes connecting them to the nose become swollen (Fashner,Ericson,& Werner, 2012). The condition is most appropriate for discussion since it expresses the same symptoms as acute sinusitis. For instance, it shows mucosal sinus swelling as thickening as also indicated by acute sinusitis.

Rhinovirus Infection

RV is also conventionally known as common cold. The symptoms of common cold include cough, fever, sore throat, nasal congestion, and headache(Casanova, Sousa, Stevens & Barlow, 2018). Cough and nasal congestion is the most experienced common symptom of common cold.

Chronic Sinusitis

The condition is accompanied by nasal airway inflammation followed by symptoms of rhinitis. Its main symptoms include stuffiness of the nasal cavity malaise and facial fullness.