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 turbinate, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
To Prepare
• With regard to the case study, you were assigned above:
• Your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
• 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?
• Refer to uploaded Learning Resources (attached)
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.