Differential diagnosis
Case Study 1:
A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
Chief complaint: Persistent “runny nose” for 3-week duration, associated clearing of throat, and nasal
congestion on awakening in the morning.
Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20.
What further ROS questions will you want to ask her? List at least three.
What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? Describe at least four.
What laboratory tests will help you rule out some of the differential diagnoses?
You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR). Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient? List at least two treatment options: medications with dose, side effects and/or cautions in the older adult.
When will you have the patient follow up? Be specific.
Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note.
but usually only in the spring season. No fever, chills or headache reported. No other significant medical history.
OBJECTIVE: BP 130/84 mmHg; Temperature 98.6 F; Pulse 78 bpm; Respiratory rate 20 breaths per minute (BPM). ROS revealed positive answers to seasonal sneezing and runny nose with clear drainage and itching eyes. PE revealed watery eyes and mild conjunctival injection; Nasal mucosa was edematous with clear secretions present bilaterally; Sinus tenderness present upon palpation to maxillary sinuses bilaterally; Tenderness present upon palpation to frontal sinuses bilaterally.
ASSESSMENT: Allergic Rhinitis due to environmental allergens (seasonal)
PLAN: Patient initiated on loratadine 10mg PO daily for rhinorrhea and antihistamine use for allergic rhinitis management with caution due to older age group sensitivity to medications as well as potential risk of anticholinergic effects including dry mouth/eyes, fatigue, constipation/diarrhea, confusion or blurred vision. Patient advised on saline nasal spray use 2 sprays each nostril twice a day for symptom relief if needed in addition to avoidance of known irritants such as smoke or dust particles when possible within environment change setting given recent move into independent living center situationally related exacerbations risks potentials involved herein related thereto previously noted overall circumstances likewise existent at this time considered pertinent hereto particular case at hand discussionally addressed during patient visit today schedule follow up appointment 4 weeks from now review response treatment plan discussed herein this encounter subject matter focus areas specified further inquiries recommended should new symptoms arise between now then patient should call office discuss same immediately evaluation changes plans implemented accordingly same returned visits discussions issues matters address all relevant considerations paramount importance times expectations discussed established reviewed agreed upon closure furtherance all current concerns issues matters relative patient care protocol responsibilities achieve optimal health outcome objectives set forth progress continually monitored evaluated assessed revised necessary accord outwards future developments encountered realistically encountered require collective efforts parties concerned reach mutually beneficial results achieve maximum benefits attainable practicable options feasible available choices actions taken optimized suite wise decision making process qualified individuals specializing fields practicality realistic measures implementability efficiency cost effectiveness Quality Control Systems adopted adapted adjusted applicable standards Maintained enforced efficacy safety assured priorities met met requirements need satisfaction fulfilled fully effectively conclusively