Nursing

To Prepare

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.

CASE ASSIGNED

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.

To Prepare

• 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.

INSTRUCTION

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.

 ANSWER

Episodic/Focused SOAP Note Template

Patient Information:

Initials: Chantal

Age: 32

Sex: Female

Race:

S.

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.

ROS:

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.

HEENT

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.

O.

Physical exam

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.

Diagnostic results

CBC-WNL

Flu Swab- Positive

Rapid Strep-Negative

A.

Differential Diagnoses

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.

References

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.