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

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

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.

The Assignment

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.

Case Study 1: This assignment you will be doing in SOAP format.

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 2 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 Exemplar

Focused SOAP Note for a patient with chest pain

S.
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
ROS
General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

second right inter-costal space which radiates to the neck.

A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel

sounds are normal in quality and intensity in all areas; a

bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary– Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: No rash or itching.

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

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

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Patient Initials: _R Age: ___50____ Gender: __M_____

SUBJECTIVE DATA

Chief Complaint (CC): For the past 5 days I have had nasal congestion, sneezing, and my nose and eyes have been itchy.

History of Present Illness (HPI): Richard is a 50 year old white male in the clinic today with a complaint of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. He denies fever, nausea or vomiting. 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. This past week he has been helping a friend in his hay field. Symptoms began a day or two after.

Medications:

Mucinex OTC QHS PRN

Lisinopril 20mg PO QD

Allergies:

NKDA

Past Medical History (PMH):

HTN

Past Surgical History (PSH):

Plate placed in left ankle and at 25 from MVA

Sexual/Reproductive History:

Heterosexual

Married, 2 children who are living outside the home

Personal/Social History:

Denies alcohol use, smoking, or drug abuse

Immunization History:

Unknown last Tdap, flu 2014

Significant Family History:

One brother, alive and no health history. Mother died from lung CA 2 years ago (age 73). Father is 76, alive and has a hx of HTN, DM and Alzheimer’s. Children are both healthy.

Review of Systems:

HEENT: nasal congestion, sneezing, runny/itchy nose, itchy eyes and ears x 5 days

Respiratory: Denies SOB, coughing, sputum production and lungs clear

Gastrointestinal: No change in bowel habits. No nausea, vomiting, diarrhea, or constipation.

GU: No dysuria, incontinence or other abnormalities

Skin: No rashes, itching, bruising. No open wounds or lacerations.

OBJECTIVE DATA

Physical Exam

Vital signs:

BP 136/74 R arm, sitting

P 79, regular

T 98.3 oral

RR 18, non-labored

Wt 223; Ht 6’1”

General: A&OX3, clean, appears ill

Neuro: AAO x4, appropriate behavior

HEENT: Denies vision or hearing alterations. Wears prescription readers. Reports allergy season being a problem this year, which is new. Lack of small/taste. Tonsils normal. Denies oral abnormalities, last saw dentist one month ago.

Neck: no abnormalities noted.

Heart: normal rate, regular, no murmur noted

Lungs: Lung sounds clear bilaterally.

Abdomen: Bowel sounds X 4 quadrants, no abnormalities noted

Genital/Rectal: not assessed

Skin: dry, warm

Musculoskeletal: no abnormalities noted

ASSESSMENT

Lab Tests/Exams and Results:

CBC-WNL

Flu Swab-Neg

Rapid Strep-Neg

Differential Diagnosis (DDx):

1. Rhinovirus- More than any other illness, rhinoviruses are associated with the common cold. Rhinoviruses may also cause some sore throats, ear infections, sinus infections (Kennedy, Heymann, & Platts-Mills, 2012).Symptoms include sore throat, runny nose, nasal congestion, sneezing and cough; sometimes accompanied by muscle aches, fatigue, malaise, headache, muscle weakness, or loss of appetite (Kennedy, Heymann, & Platts-Mills, 2012).

2. Acute sinusitis- Inflammation of one or all of the paranasal sinuses is often referred to as sinusitis –can be it infectious or non-infectious in etiology (Hawthorne & Ahmad, 2010). The vast majority of infectious causes are acute, self-limited viral infections (Hawthorne & Ahmad, 2010). Symptoms include: nasal obstruction/congestion; anterior discharge/postnasal drip; facial pain/pressure and/or reduction/loss of smell (Hawthorne & Ahmad, 2010).

3. Allergic rhinitis- Allergic rhinitis, also called hay fever, is the group of uncomfortable symptoms that occur when your body is exposed to a specific allergen (de Corso et al., 2014). An allergen is a typically harmless substance, such as grass or dust, which causes an allergic reaction (de Corso et al., 2014). Pollen is the most common allergen for most people (de Corso et al., 2014). Since Richard has been working in the hay field the week prior, this concludes the diagnosis. Uncomfortable symptoms of allergic rhinitis include runny nose, sneezing, and itchy eyes (de Corso et al., 2014).

4. Sinus obstruction- The sinuses are small, hollow chambers inside the nose and head that reduce the weight of the facial bones, give the bones shape and support, assist in mucus drainage from the nose, and help the voice resonate (Kennedy & Borish, 2013).Healthy sinuses are filled with air. When their mucous membranes swell from allergies, the common cold, infection or other causes, the narrow sinus openings become blocked, the pressure inside them drops, and they can fill with fluid, which easily leads to bacterial infection (Kennedy & Borish, 2013).

5. Chronic Sinusitis- Chronic sinusitis is a common condition in which the cavities around nasal passages become inflamed and swollen — for at least eight weeks, despite treatment attempts (Kennedy & Borish, 2013). This condition interferes with drainage and causes mucus to build up. It can make it difficult to breathe through your nose. The area around your eyes and face may feel swollen, and you may have throbbing facial pain or a headache (Kennedy & Borish, 2013). Symptoms of chronic sinusitis are less obvious and may include nasal blockage or congestion, post-nasal drip, reduced sense of smell, and malaise (Kennedy & Borish, 2013).

References

de Corso, E., Battista, M., Pandolfini, M., Liberati, L., Baroni, S., Romanello, M., & … Paludetti, G. (2014). Role of inflammation in non-allergic rhinitis. Rhinology, 52(2), 142-149. doi:10.4193/Rhin

Hauk, L. (2014). AAP releases guideline on diagnosis and management of acute bacterial sinusitis in children one to 18 years of age. American Family Physician, 89(8), 676-681. Retrieved from: http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=8&sid=642c28f0-7af4-4bb2-b3b0-bafbb5861d8a%40sessionmgr110&hid=106

Hawthorne, M. R., & Ahmad, N. (2010). Acute sinusitis: pitfalls in diagnosis and management. Clinical Risk, 16(6), 209-212. doi:10.1258/cr.2010.010052

Kennedy, J. L., & Borish, L. (2013). Chronic sinusitis pathophysiology: the role of allergy. American Journal Of Rhinology & Allergy, 27(5), 367-371. doi:10.2500/ajra.2013.27.3906

Kennedy, J. L., Heymann, P. W., & Platts-Mills, T. E. (2012). The role of allergy in severe asthma. Clinical And Experimental Allergy: Journal Of The British Society For Allergy And Clinical Immunology, 42(5), 659-669. doi:10.1111/j.1365-2222.2011.03944.x

Patient Initials
: _R
Age
: ___50____
Gender:

__M_____

SUBJECTIVE DATA

Chief Complaint (CC):

For the past 5 days I have had
nasal congestion, sneezing
, and my nose and eyes
have been itchy.

History of Present
Illness (HPI):

Richard is a 50 year old white male in the clinic today with a complaint
of
nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy
nose, eyes, palate, and ears for 5 days
. He denies fever, nausea
or vomiting.
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 en
larged but his throat is mildly
erythematous.

This past week he has been helping a friend in his hay field.
Symptoms began a day or
two after.

Medications:

Mucinex OTC QHS PRN

Lisinopril 20mg PO
QD

Allergies:

NKDA

Past Medical History (PMH):

HTN

Past Surgical History (PSH):

Plate placed in left ankle and at 25 from MVA

Sexual/Reproductive History:

Heterosexual

Married, 2 children who are living outside the home

Personal/Social History:

Denies

alcohol use, smoking, or drug abuse

Immunization History:

Unknown last Tdap, flu 2014

Significant Family History:

One brother, alive and no health history. Mother died from lung CA 2 years ago (age 73). Father
is 76, alive and has a hx of HTN, DM and Al
zheimer’s. Children are both healthy.

Patient Initials: _R Age: ___50____ Gender: __M_____
SUBJECTIVE DATA
Chief Complaint (CC): For the past 5 days I have had nasal congestion, sneezing, and my nose and eyes
have been itchy.
History of Present Illness (HPI): Richard is a 50 year old white male in the clinic today with a complaint
of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy
nose, eyes, palate, and ears for 5 days. He denies fever, nausea or vomiting. 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. This past week he has been helping a friend in his hay field. Symptoms began a day or
two after.
Medications:
Mucinex OTC QHS PRN
Lisinopril 20mg PO QD
Allergies:
NKDA
Past Medical History (PMH):
HTN
Past Surgical History (PSH):
Plate placed in left ankle and at 25 from MVA
Sexual/Reproductive History:
Heterosexual
Married, 2 children who are living outside the home
Personal/Social History:
Denies alcohol use, smoking, or drug abuse
Immunization History:
Unknown last Tdap, flu 2014
Significant Family History:
One brother, alive and no health history. Mother died from lung CA 2 years ago (age 73). Father
is 76, alive and has a hx of HTN, DM and Alzheimer’s. Children are both healthy.

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: No rash or itching.

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

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

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Case Study # 1

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

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