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

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.

 

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Case Study 1: Focused Nose Exam

A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. She has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. Her tonsils are not enlarged but his throat is mildly erythematous.

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