By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
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 five possible conditions that may be considered in a differential diagnosis for the patient.
Chantal, a 32-year-old female, comes into your office with complaints of “feeling tired” and “hair falling out”. She has gained 30 pounds in the last year but notes markedly decreased appetite. On ROS, she reports not sleeping well and feels cold all the time. She is still able to enjoy her hobbies and does not believe that she is depressed.
With regard to the case study you were assigned:
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources.
Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.
List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Episodic/Focused SOAP Note Template
CC (chief complaint): The patient is complaining of feeling tired and hair falling out.
HPI: Chantal a 32-year-old female comes into the clinic complaining of 3 days of feeling tired and hair falling out. In the last year, she gained 30 pounds but has marked decreased appetite. The client complains of feeling cold all the time, nasal congestion, not sleeping well, rhinorrhea, and postnasal drainage. She also complains of itchy nose, eyes, palate, and nose.
Current Medications: Mucinex OTC QHS PRN; Lisinopril 20mg PO QD
Allergies: No known allergies and no known drug allergies for the patient.
PMHx: The patient has been diagnosed with Hypertension. Pins were placed in the ankle after a fracture during a road accident. Pneumonia vaccine winter 2015 and Flu Vaccine 2016.
Soc Hx: She denies smoking, alcohol, and any other form of drug abuse.
Fam Hx: The patient is the primary caregiver to her mother who has dementia. The patient states that she has excellent social support from her family. Chantal lives with her mother and her family which consists of the husband and two married children still living with her.
GENERAL: She complains of feeling tired, not sleeping well, and feeling cold all the time. Chantal has gained 30 pounds over the last year but has noted markedly reduced appetite. She is still able to carry on with her duties and hobbies and believes that she is not depressed.
Eyes: Denies that there are any changes in vision other than watery eyes and itchiness. The patient has no history of glaucoma, photophobia, cataracts, and diplopia.
Nose: Nasal congestion, clear nasal drainage and has been sneezing for the last five days.
Ears: No drainage, no recent infections, ears are normal bilaterally.
Mouth: No difficulty in swallowing or chewing encountered. No dental caries, bad breath, mouth sores, gum disease, or tooth erosion observed.
Skin: No lacerations, itching, rashes, bruising, or open wounds.
Cardiovascular: Denied palpitations, no chest pains, and no arrhythmia history.
Respiratory: Denies coughing, SOB, lungs clear, and no sputum production.
Gastrointestinal: No vomiting, constipation, diarrhea or nausea, or change in bowel habits.
Genitourinary: Denies hesitancy, incontinence, frequency, and dysuria, or any other abnormalities.
Neurological: No seizures, falls, and migraines.
Musculoskeletal: No osteoporosis, no back pain, no joint pain, stiffness, or muscle ache.
HEMATOLOGIC: No sickle cell disease, no complications from transfusion or chemotherapy, no bleeding, or any hematologic diseases.
LYMPHATICS: No enlarged lymph nodes, no swollen glands, or any lymphatic diseases.
PSYCHIATRIC: No history of anxiety or depression.
ENDOCRINOLOGIC: No adrenal insufficiency and polydipsia. The patient reports feeling cold all the time.
ALLERGIES: No history of any known allergies or drug allergies.
Vital signs: Bp 130/85, RR 15, T 97.9 oral, Heart rate 80 beats per minute, Wt. 91 lbs.
General: appears fatigued, clean, oriented, and alert.
HEENT: Reports lack of taste and smell denies hearing and vision changes, denies oral abnormalities.
Flu Swab- Positive
Influenza – the rapid influenza test detected influenza viral antigens in respiratory tract specimens. Some of the symptoms of flu include feeling feverish, body aches, runny nose, and tiredness (Moghadami, 2017). The patient with serious complications can develop multi-organ failure, muscle ache, difficulty in breathing or shortness of breath, and inflammation of the heart.
Rhinovirus – The disease is mostly linked to sore throats, common cold, and sinus infections. The rhinovirus can also result from symptoms of sneezing, breathing difficulties, congestion, cough, runny nose, weakness, headache, loss of appetite, muscle aches, and fatigue (Dissanayake et al., 2020).
Acute Sinusitis – This disease is linked to short inflammation of the membranes aligning the nose thus affecting one’s ability to drain mucus (Ebell et al., 2019). Some of the symptoms linked to the disease include facial pain, loss of smell, nasal obstruction, postnasal drip, and anterior discharge.
Allergic Rhinitis – This is a type of inflammation in the nose that happens when the immune system tends to overreact to allergens (Demoly, Bossé, and Maigret, 2020). Some of the signs and symptoms linked to Allergic Rhinitis include stuffy nose, watery eyes, itchy eyes, sneezing, and dark clouding around the eyes.
Chronic Sinusitis- This infection occurs when the activities within the nasal passages are inflamed. The spaces inside the sinuses are inflamed and swollen thus interfering with the normal mucus drainage leading to a stuffy nose (Hong, Pereyra, Guo, Breslin and Melville, 2017). The symptoms of chronic sinusitis include congestion or blockage of the nasal activity, low sense of smell, postnasal drainage, and fatigue.
Demoly, P., Bossé, I., & Maigret, P. (2020). Perception and control of allergic rhinitis in primary care. npj Primary Care Respiratory Medicine, 30(1), 1-6.
Dissanayake, T. K., Schäuble, S., Mirhakkak, M., Wu, W. L., Ng, A. C. K., Yip, C. C., … & Panagiotou, G. (2020). Comparative transcriptomic analysis of rhinovirus and influenza virus infection. Frontiers in Microbiology, 11, 1580.
Ebell, M. H., McKay, B., Dale, A., Guilbault, R., & Ermias, Y. (2019). Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. The Annals of Family Medicine, 17(2), 164-172.
Hong, P., Pereyra, C. A., Guo, U., Breslin, A., & Melville, L. (2017). Evaluating complications of chronic sinusitis. Case reports in emergency medicine, 2017.
Moghadami, M. (2017). A narrative review of influenza: a seasonal and pandemic disease. Iranian journal of medical sciences, 42(1), 2.
Plagiarism Free Papers
All our papers are original and written from scratch. We will email you a plagiarism report alongside your completed paper once done.
All papers are submitted ahead of time. We do this to allow you time to point out any area you would need revision on, and help you for free.
A title page preceeds all your paper content. Here, you put all your personal information and this we give out for free.
Without a reference/bibliography page, any academic paper is incomplete and doesnt qualify for grading. We also offer this for free.
Originality & Security
At Homework Sharks, we take confidentiality seriously and all your personal information is stored safely and do not share it with third parties for any reasons whatsoever. Our work is original and we send plagiarism reports alongside every paper.
24/7 Customer Support
Our agents are online 24/7. Feel free to contact us through email or talk to our live agents.
Try it now!
How it works?
Follow these simple steps to get your paper done
Place your order
Fill in the order form and provide all details of your assignment.
Proceed with the payment
Choose the payment system that suits you most.
Receive the final file
Once your paper is ready, we will email it to you.
We work around the clock to see best customer experience.
Our prces are pocket friendly and you can do partial payments. When that is not enough, we have a free enquiry service.
Admission help & Client-Writer Contact
When you need to elaborate something further to your writer, we provide that button.
We take deadlines seriously and our papers are submitted ahead of time. We are happy to assist you in case of any adjustments needed.
Your feedback, good or bad is of great concern to us and we take it very seriously. We are, therefore, constantly adjusting our policies to ensure best customer/writer experience.