Assignment: Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders

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Head, neck, and face disorders are common, and thus you will likely care for elderly patients with these disorders. In your role as an advanced practice nurse, you must be able not only to correctly assess and diagnose patients but also help patients manage the disorder by planning necessary treatments, assessments, and follow-up care.

To prepare:

Review the case study provided by your Instructor.
Reflect on the patient’s symptoms and aspects of disorders that may be present.
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.  Female Diagnosed with Allergic Rhinitis Essay Example

Focused SOAP Note for a 76 Year-Old Female Diagnosed with Allergic Rhinitis
Patient Information:
Initials: MN Age: 76 years Gender: Female Race: Caucasian
Subjective:
CC (chief complaint): The patient was seen with complaints of difficulty clearing her throat, persistent rhinorrhea or “runny nose”, and on-and-off nasal congestion x 3 weeks; all of which are more pronounced when she wakes up in the morning.
HPI: The patient is a 76 year-old Caucasian female who presents with the above symptoms. She admits to having a previous history of these symptoms especially in spring. The onset of the current symptoms was three weeks before and it is the nasal cavity that is involved. The nasal congestion is intermittent but the runny nose and clearing her throat are almost constantly there. The symptoms are characteristically persistent and nagging and are aggravated by the morning cold weather. Over-the-counter guaifenesin (Mucinex) has been relieving the symptoms somewhat for the past two weeks but they come back. As stated above, these symptoms are worse in the mornings on waking up. The patient rates their severity at 7/10.

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Current Medications: Guaifenesin (Mucinex) 600 mg twice a day (OTC) to loosen secretions in the throat.
Allergies: She admits to having a history of allergy to pollen. There is however no history of asthma, hives, or allergy to foods or drugs.
PMHx: She states that she has been admitted three times before for lobar pneumonia, gastroenteritis, and diverticular disease. She underwent total abdominal hysterectomy at the age of 38 years due to gross uterine leiomyomas.
Soc Hx: She recently moved into a residential aged-care facility (RACF) after independently staying at her home for forty years. She is a retired teacher with four children who are all grown and living with their families.
Family Hx: She is a mother of four and grandmother to sixteen. There is significant history of allergies within the family on her paternal side. However, there is no history of other chronic illnesses apart from diverticular disease.
ROS:
• GENERAL: She denies weight loss, fever, or chills but accepts she has malaise and fatigue.
• HEENT: Negative for headaches, diplopia, photophobia, tearing, otorrhea, tinnitus, or dysphagia/ sore throat. POSITIVE for rhinorrhea, nasal congestion, and sneezing.
• SKIN: Denies itchy skin or rashes.
• CARDIOVASCULAR: Denies palpitations, chest pains or tightness, and edema.
• RESPIRATORY: Denies respiratory distress, dyspnea, wheezing, or coughing.
• GASTROINTESTINAL: Denies changes in bowel habits, diarrhea, vomiting, or nausea. Latest bowel movement was in the morning.
• GENITOURINARY: Denies hesitancy, bladder incontinence, frequency of micturition, polyuria, or oliguria. She is post-menopausal.
• NEUROLOGICAL: Denies feeling pins and needles in extremities, fainting, or paresis.
• MUSCULOSKELETAL: Reports occasional myalgia and arthralgia.
• HEMATOLOGIC: Denies any hematological conditions such as clotting disorders.
• LYMPHATICS: Negative for splenectomy or cervical, axillary, and inguinal lymphadenopathy.
• ENDOCRINOLOGIC: Denies polydipsia, polyphagia, heat/ cold intolerance, or excessive sweatiness. She also denies ever having hormonal therapy. Female Diagnosed with Allergic Rhinitis Essay Example

Objective:
Physical Examination
General: The patient is alert, oriented, and lucid. She is negative for any cognitive deficiencies. Vitals: T 98.6°F; BP 130/84 mmHg; RR 20 breaths/ min; HR 78 b/m.
HEENT: The head is normocephalic with no outward signs of trauma. Both pupils are round and equal and react to light and accommodation (PERRLA). Extraocular muscles are intact (EOMI). The pinna and tragus show no trauma. Tympanic membranes show normal light reflex bilaterally. The nasal turbinates are inflamed and reddened. A copious amount of thin watery mucus is running out of the nostrils. The nasal septum is midline. There is no thrush or erythema in the pharynx.
Cardiovascular: S1 and S2 audible with no murmurs, bruit, or rubs.
Respiratory: Clear lung fields with no dyspnea or use of accessory muscles. No crepitations or rales. No wheezing, grunting, or stridor.
Diagnostic Results:
• A plain chest X-ray is negative for lung consolidation.
• IgE antibodies confirm allergy.
• Nasal endoscopy shows diffuse intranasal inflammation consistent with allergic rhinitis (Hammer & McPhee, 2018; Huether & McCance, 2017).
• WBC 5.3 x 109/L (no leucocytosis).
Assessment:
Differential Diagnoses
1. Allergic Rhinitis or AR (Hammer & McPhee, 2018; Bozek, 2017; Baptist & Nyenhuis, 2016): Because of the positive history of allergy in the patient and her family, this is the most probable diagnosis for her. She can positively correlate the same symptoms seen previously with environmental factors (pollen).
2. Rhinitis medicamentosa (Hammer & McPhee, 2018; Bozek, 2017; Baptist & Nyenhuis, 2016): This is the second most likely diagnosis and it relates to rhinitis that comes about as a result of the use of medications such as decongestants and antihypertensives.
3. Anatomic rhinitis due to nasal tumor (Hammer & McPhee, 2018; Bozek, 2017; Baptist & Nyenhuis, 2016): This is the third differential in terms of priority. It is an unlikely prospect since the nasal endoscopy ruled out any tumors.
Plan:
• Pharmacotherapy: start cetirizine (Zyrtec) 10 mg orally once daily (Bozek, 2017). This antihistamine is chosen because it does not cause drowsiness, something that would put the septuagenarian at risk of accidental falls.
• For rhinitis medicamentosa, withdraw the medication that is causing the rhinitis.
• For intranasal tumor, the patient is referred for oncology assessment.
• Health promotion and education is given concerning the need to avoid environmental irritants and triggers.
• Follow up for this patient will be after a week.

Reflections
Considering the assessment and management offered to this patient as above, I would still follow the same process were I to be required to do it again. To get the subjective information required and to follow bioethical principles, informed consent was obtained before any procedure was done. This means the principle of autonomy was respected. Insights that I came out with include that rhinitis is a common but ignored condition in the elderly. Therefore the important lesson learnt is that thorough assessment and diagnostic testing must be carried out in order not to misdiagnose cases of rhinitis in the elderly.
References
Baptist, A.P., & Nyenhuis, S. (2016). Rhinitis in the elderly. Immunology and Allergy Clinics of North America, 36(2), 343–357. https://doi.org/10.1016/j.iac.2015.12.010
Bozek, A. (2017). Pharmacological management of allergic rhinitis in the elderly. Drugs & Aging, 34(1), 21–28. https://doi.org/10.1007/s40266-016-0425-7
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. New York, NY: McGraw-Hill Education.
Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. St. Louis, MO: Elsevier, Inc.  Female Diagnosed with Allergic Rhinitis Essay Example