Case Study 1: Focused Nose
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. 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.
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.
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.
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.
TO PREPARE
• By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
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?
Sample Solution
Presenting Complaint:
A 28-year-old female presents to the clinic complaining of a runny nose, itchy eyes, and ears feeling full. She states that these symptoms began approximately 9 days ago and follow a seasonal pattern, typically occurring every spring and lasting for 6-8 weeks.
Additional Symptoms:
- Runny nose with clear mucus
- Sneezing on and off throughout the day
- Severe eye itching, sometimes accompanied by a tickling sensation in the throat
- Ears feeling full and occasionally popping
Full Answer Section
ast Medical History:
- Seasonal allergic rhinitis, managed with Claritin in the past with relief
Physical Examination:
- Alert and oriented
- Pale, boggy nasal mucosa with clear, thin secretions
- Enlarged nasal turbinates obstructing airway flow
- Clear lungs
- Tonsillar erythema without enlargement
Differential Diagnosis:
Based on the patient's presentation, history, and physical examination, several conditions must be considered in the differential diagnosis:
- Allergic rhinitis: This is the most likely diagnosis given the seasonal pattern of symptoms, runny nose, sneezing, itchy eyes, and history of successful treatment with Claritin. The boggy nasal mucosa, clear secretions, and enlarged turbinates further support this diagnosis.
- Viral rhinitis: While common, viral rhinitis typically resolves within a few days, unlike the 9-day duration in this case. Additionally, viral rhinitis usually presents with fever, malaise, and cough, which are absent in this patient.
- Bacterial rhinosinusitis: This condition can cause nasal discharge, facial pain or pressure, and fever. However, the lack of fever and facial pain makes this diagnosis less likely.
- Chronic sinusitis: Chronic sinusitis can present with nasal discharge, congestion, and facial pain or pressure. However, the seasonal pattern and lack of facial pain argue against this diagnosis.
- Hay fever: Hay fever is another term for allergic rhinitis and would present similarly in this case.
- Conjunctivitis: While the patient’s itchy eyes could be related to allergic rhinitis, conjunctivitis can also cause similar symptoms. Further examination would be needed to differentiate these two conditions.
Further Workup:
- Nasal endoscopy: This procedure allows for a direct visualization of the nasal passages and sinuses to confirm the presence of inflammation or other abnormalities.
- Allergy testing: Skin prick tests or serum IgE testing can help identify specific allergens that might be triggering the patient's symptoms.
Management:
- Antihistamines: Oral antihistamines like Claritin (loratadine) or Zyrtec (cetirizine) can help alleviate symptoms like runny nose, sneezing, and itchy eyes.
- Nasal corticosteroids: Topical nasal corticosteroids like Flonase (fluticasone) or Nasonex (mometasone) can reduce inflammation and nasal congestion.
- Eye drops: Antihistamine or corticosteroid eye drops can help relieve itchy eyes.
- Nasal saline irrigation: Rinsing the nasal passages with a saline solution can help clear mucus and soothe irritated tissues.
Education:
- Educate the patient about the management strategies mentioned above.
- Discuss environmental triggers and avoidance strategies for managing allergies.
- Encourage the patient to follow up with a healthcare provider if symptoms worsen or do not improve with treatment.
Conclusion:
This case study demonstrates the importance of considering a differential diagnosis when a patient presents with common symptoms like a runny nose and itchy eyes. While allergic rhinitis is the most likely diagnosis in this case, further workup may be necessary to rule out other possibilities. Prompt and appropriate management can significantly improve the patient's quality of life and prevent complications.