Make a SOAP Note: Assessing Ear, Nose, and Throat 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. 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. In this Discussion, 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. Note: By Day 1 of this week, your instructor will have assigned you to one of the following case studies to review for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case. Case 1:  Nose Focused Exam 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 two 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 turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. Case 2:  Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus over the past two weeks, Lily figured she shouldn't take her three-day sore throat lightly. Your clinic has treated a few cases similar to Lily's. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn't sound congested. Case.

1. Make a SOAP Note: Assessing Ear, Nose, and Throat
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. 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.
In this Discussion, 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.
Note:
By Day 1 of this week, your instructor will have assigned you to
one of the following case studies to review for this Discussion.
Also, your Discussion post should be in the SOAP Note format,
rather than the traditional narrative style Discussion posting
format. Refer to Chapter 2 of the Sullivan text and the
Comprehensive SOAP Template in the Week 4 Learning
Resources for guidance.
Remember that not all comprehensive SOAP data are included
in every patient case.
Case 1:
Nose Focused Exam
Richard is a 50-year-old male with nasal congestion, sneezing,
rhinorrhea, and postnasal drainage. Richard has struggled with

2. 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 two 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 turbinates, which obstruct airway flow but his
lungs are clear. His tonsils are not enlarged but his throat is
mildly erythematous.
Case 2:
Focused Throat Exam
Lily is a 20-year-old student at the local community college.
When some of her friends and classmates told her about an
outbreak of flu-like symptoms sweeping her campus over the
past two weeks, Lily figured she shouldn't take her three-day
sore throat lightly. Your clinic has treated a few cases similar to
Lily's. All the patients reported decreased appetite, headaches,
and pain with swallowing. As Lily recounts these symptoms to
you, you notice that she has a runny nose and a slight
hoarseness in her voice but doesn't sound congested.
Case 3:
Focused Ear Exam
Martha brings her 11-year old grandson, James, to your clinic to
have his right ear checked. He has complained to her about a
mild earache for the past two days. His grandmother believes
that he feels warm but did not verify this with a thermometer.
James states that the pain was worse while he was falling asleep
and that it was harder for him to hear. When you begin basic
assessments, you notice that James has a prominent tan. When
you ask him how he's been spending his summer, James
responds that he's been spending a lot of time in the pool.

3. To prepare:
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?
·
Identify at least 10 possible conditions that may be considered
in a differential diagnosis for the patient.
Note:
Before you submit your initial post, replace the subject line
(“Week 5 Discussion”) with “Review of Case Study ___,”
identifying the number of the case study you were assigned.
Address the following in the SOAP Note:
1.
A description of the health history you would need to collect
from the patient in the case study to which you were assigned.
2.
Explain what physical exams and diagnostic tests would be
appropriate and how the results would be used to make a
diagnosis.
3.

4. List five different possible conditions for the patient's
differential diagnosis and justify why you selected each.
REFERENCES:
Readings
·
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015).
Seidel's guide to physical examination
(8th ed.). St. Louis, MO: Elsevier Mosby.
o
Chapter 10, “Head and Neck” (pp. 184-203)
This chapter reviews the anatomy and physiology of the head
and neck. The authors also describe the procedures for
conducting a physical examination of the head and neck.
o
Chapter 11, “Eyes” (pp. 204-230)
In this chapter, the authors describe the anatomy and function of
the eyes. In addition, the authors explain the steps involved in
conducting a physical examination of the eyes.
o
Chapter 12, “Ears, Nose, and Throat” (pp. 231-259)
The authors of this chapter detail the proper procedures for
conducting a physical exam of the ears, nose, and throat. The
chapter also provides pictures and descriptions of common
abnormalities in the ears, nose, and throat.
·

5. Dains, J. E., Baumann, L. C., & Scheibel, P. (2016).
Advanced health assessment and clinical diagnosis in primary
care
(5th ed.). St. Louis, MO: Elsevier Mosby.
o
Chapter 15, “Earache” (pp. 174–183)
This chapter covers the main questions that need to be asked
about the patient’s condition prior to the physical examination,
as well as how these questions lead to a focused physical
examination.
o
Chapter 21, “Hoarseness” (pp. 248-255)
This chapter focuses on the most common causes of hoarseness.
It provides strategies for evaluating the patient both through
questions and through physical exams.
o
Chapter 25, “Nasal Symptoms and Sinus Congestion” (pp.301-
309)
In this chapter, the authors highlight the key questions to ask
about the patients symptoms, the key parts of the physical
examination, and potential laboratory work that might be
needed to provide an accurate diagnosis of nasal and sinus
conditions.
o
Chapter 30, “Red Eye” (pp. 357-368)
The focus of this chapter is on how to determine the cause of
red eyes in a patient, including key symptoms to consider and
possible diagnoses.

6. o
Chapter 32, “Sore Throat” (pp. 381-389)
A sore throat is one most common concerns patients describe.
This chapter includes questions to ask when taking the patient’s
history, things to look for while conducting the physical exam,
and possible causes for the sore throat.
o
Chapter 38, “Vision Loss” (pp. 446-457)
This chapter highlights the causes of vision loss and how the
causes of the condition can be diagnosed.
·
Sullivan, D. D. (2012).
Guide to clinical documentation
(2nd ed.). Philadelphia, PA: F. A. Davis.
o
Chapter 5, "SOAP Notes" (pp. 91–118)
Note:
Download the seven documents (Adult Examination Checklists
and Physical Exam Summaries) below, and use them as you
practice conducting assessments of the head, neck, eyes, ears,
nose, and throat.
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Adult examination checklist: Guide for head, face, and neck
. In
Mosby's guide to physical examination

7. (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Head, Face, and
Neck was published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Adult examination checklist: Guide for eye assessment
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Eye Assessment
was published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Adult examination checklist: Guide for ear assessment
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Ear Assessment
was published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·

8. Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Adult examination checklist: Guide for nose, paranasal sinuses,
mouth, oropharynx
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Nose, Paranasal
Sinuses, Mouth, Oropharynx was published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Physical exam summary: Ears, nose, and throat
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Ears, Nose, and Throat Physical Exam Summary was
published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Physical exam summary: Eyes
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.

9. This Eyes Physical Exam Summary was published as a
companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Physical exam summary: Head, face, and neck
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Head and Neck Physical Exam Summary was published as
a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Browning, S. (2009). Ear, nose, and throat problems.
General Practice Update
,
2
(9), 9–13.
Retrieved from the Walden Library databases.
This article contains a question and answer session on ear, nose,
and throat problems. The article reviews specific topics, such as
when to use eardrops and new post-nasal drip treatments, and
the referral of persisting cough cases by general practitioners.

10. ·
Lloyd, A., & Pinto, G. L. (2009). Common eye problems.
Clinician Reviews
,
19
(11), 24–29.
Retrieved from the Walden Library databases.
The authors of this article describe different eye problems, their
symptoms, and recommended treatments. The authors also
emphasize the need to conduct an eye exam and take an ocular
history.
·
Otolaryngology Houston. (2014).
Imaging of maxillary sinusitis (X-ray, CT, and MRI)
. Retrieved from
http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
This website provides medical images of sinusitis, including X-
rays, CT scans, and MRIs (magnetic resonance imaging).
Media
Online media for
Seidel's Guide to Physical Examination
It is highly recommended that you access and view the
resources included with the course text,
Seidel's Guide to Physical Examination
. Focus on the videos and animations in Chapters 10, 11, and 12
that relate to the assessment of the head, neck, eyes, ears, nose,
and throat. Refer to Week 4 Learning Resources area for access

11. instructions on
https://evolve.elsevier.com/
.
Optional Resources
·
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009).
DeGowin’s diagnostic examination
(9th ed.). New York, NY: McGraw Hill Medical.
o
Chapter 7, “The Head and Neck” (pp. 178–301)
This chapter describes head and neck examinations that can be
made with general clinical resources. Also, the authors detail
syndromes of common head and neck conditions.