NR 509 week 2
Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included. You may include the assessment and plan portion of the SOAP note, but these sections will not be graded.
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You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of sinus congestion, rash, and abdominal pain. You should also focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.
* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often. NR 509 week 2
SOAP Note
Patient Information:
Initials T.K Age 30. , Sex female. Race Jewish descent Insurance United Health
Chief Complain: Sinus Congestion, Abdominal pain and rash
Assessment:
Onset of flare up: 3 days ago
Abdominal pain related to flare up from ulcerative colitis, fatigued, weight loss, chronic diarrhea with or without blood.
When percussed the abdomen had drum like sound due to inflammation and patient grimaced when palpated.
Vital Signs: B/P 120/70, HR 85 RR, 26, T 98.3, height 5.7, weight 120 lb
Sinus Congestion, Abdominal pain and rash NR 509 week 2
Abdominal pain: Cramping, aching and bloating pain present
Aggravating Factors: bloating, diarrhea random cramping/aching bothersome pain.
Relieving Factors: Anti-diarrhea Motrin 200 mg with food as needed for pain.
Differential Diagnosis: Ulcerative colitis, Sinusitis and urticaria
Current Medications: Imodium AD
Ibuprofen 200 mg, take 1 caplet every 4 to 6 hours while symptoms persist
If pain does not respond to 1 caplet, 2 caplets may be used
Allergies: Hives when exposed to cold weather (Cold intolerance)
Patients Medical History: Sinusitis, Ulcerative colitis and headaches
Chronic diarrhea with or without blood, persistent desire to empty bowel, anorexia, nausea, vomiting present.
Last PCP visit and annual exam 2 weeks ago
Flu shot: current
Family history:
Father: Suffers from mild Ulcerative Colitis
Mother: Active healthy and owns cleaning business, had years of secondary infertility after client was born.
Siblings: None
Psychosocial History: Close relationship with both parents and Feels safe in home environment with parents.
Hobbies: reading and watching movies
ROS:
CONSTITUTIONAL: No weight loss, sinusitis, abdominal pain and rash present
HEENT:
Head: Hair texture appears very soft and malnourished.
Eyes: patient is using contact lens. Last eye exam 7 months ago & WNL. No visual loss, blurred vision, double vision or yellow sclera noted. Conjunctival sac pale.
Ears: No hearing loss or drainage noted
Nose: Sinus congestion, runny nose, sneezing present, grimaced when sinus was palpated.
Throat: No abnormal findings noted
SKIN: warm, dry, rash and mild itching noted.
CARDIOVASCULAR: Breath sounds clear and equal bilaterally. Heart S1 S2, neither accentuated nor diminished. No murmur or extra heart sounds. No palpitations noted
RESPIRATORY: Admits having shortness of breath with regular activities, such as climbing stairs, walking short distance sometimes and no coughing present.
GASTROINTESTINAL: Abdominal pain present, weight loss apparent. Drum like sound when percussed, frequent diarrhea from ulcerative colitis flare ups. Abdominal pain related to disease process present. TK grimaced when palpated
GENITOURINARY: patient denies signs and symptoms of UTI, denies hesitancy, urgency, burning, no complaints reported.
NEUROLOGICAL: Patient denies dizziness, vertigo, but fatigued and tingling, loss of sensation. No change in bowel or bladder control.
MUSCULOSKELETAL: Extremities warm and equal bilaterally. All pulses present, 2+ and equal bilaterally. No lymphadenopathy present. Sensory modalities intact in legs and feet. No lesions noted.
HEMATOLOGIC: Anemia noted, blood present in stool sometimes.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: patient has no history of depression but needs social support and a lot of encouragement to deal with disease process. Strong family ties present.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. Lactose intolerance present
Differential Diagnosis for Rash
Urticaria
Urticaria (hives) is a pruritic, often immune-mediated skin eruption of well-circumscribed wheals on an erythematous base as cited by (Wanderer, 2000). Urticaria is the consequence of a mast cell release of mediators that increase vascular permeability, which leads to extravasation into the skin of protein-rich fluid from small blood vessels, usually post capillary venules. It is estimated that up to one fifth of the population will experience an urticarial episode and women are more likely to be affected than men however menstrual cycle can predispose a woman to urticarial or other erythematous rash especially, during the premenstrual time period. The condition could worsen three to 10 days prior to the onset of menses. Most chronic urticaria resolves within 1 year, although persistent ones occurs in approximately 10% of cases. Many mechanisms have been implicated, and much remains incompletely understood, but mast cell activation is usually the final common pathway. Precipitants range from physical stimuli to autoimmune mechanisms. Heat, fever, emotional stress, alcohol, and premenstrual state. All of these stated precipitants can exacerbate urticaria, independent of the specific pathophysiology. Additional precipitants and mediators of the urticarial reaction are constantly being identified. The localized accumulation of fluid produces the characteristic edematous, erythematous, well-circumscribed itchy wheals, which blanch on pressure, range in size from a few millimeters to several centimeters, and manifests with serpiginous borders. Individual lesions may persist for 12 to 24 hours, but most resolve spontaneously much sooner. NR 509 week 2
Laboratory work: history is the most useful component of the evaluation and yields clues to an underlying cause or precipitant far more often than does the physical examination or laboratory studies.
Treatment
Antihistamines provide excellent symptomatic control. The H1blockers, such as hydroxyzine (10 to 25 mg daily at bedtime) and diphenhydramine (25 to 50 mg daily at bedtime), have been the mainstay of antihistamine therapy depending on the severity. These medications are inexpensive and effective but have a sedating effect. The non-sedating H1 blockers (e.g., fexofenadine 60 mg or cetirizine 10 mg every morning) are also effective and are better tolerated for daytime use. It is often best to use a non-sedating antihistamine during the day and a more sedating agent at night. Chlorpheniramine and diphenhydramine are useful alternatives for nighttime use because they are available over the counter and are less expensive.
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD). Of the large intestine that affects the mucosal layer beginning in the rectum and colon and spreading into the adjacent tissue. Although the exact etiology of UC is unclear, it appears to be the result of an abnormal inflammatory response to intestinal microbes in genetically susceptible individuals. Predominant symptoms of UC are frequent and bloody diarrhea, cramping, abdominal tenderness, rectal bleeding, and intermittent tenesmus (i.e., straining or feeling urgency to defecate without a productive bowel movement). Severe disease is indicated by bloody or nocturnal diarrhea, weight loss, and low energy levels. Pallor, constipation, anorexia, severe weight loss, fever, vomiting, dehydration, tachycardia, and extra intestinal disease manifestations can be present. Ulcerative Colitis sufferer’s relapses or goes into remission sometimes. Mild UC is characterized by < 4 bowel movements per day with or without blood, no signs of toxicity, and normal erythrocyte sedimentation rate (ESR). Moderate UC is characterized by > 4 bowel movements per day and minimal signs of toxicity. In severe disease, bowel movements are more frequent (> 6/day) and there is evidence of toxicity, such as fever, tachycardia, anemia, and elevated ESR. NR 509 week 2. Extra intestinal disease affects 10–15% of patients with UC and can involve the joints, skin, mouth, and eyes, or manifest as liver disease, gallstones, kidney stones, peptic ulcer disease, osteoporosis, mal-absorption, amyloidosis, or thromboembolic disease. Possible complications include perforation, pseudo-polyps, toxic mega-colon, colorectal cancer (CRC), skin disorders, arthritis, lung disease, thromboembolism, and hemolytic anemia. UC is diagnosed based on patient history, physical examination, laboratory testing, radiography, and colonoscopy. 9–12 new cases per 100,000 persons diagnosed each year. Age at onset of UC shows a bimodal distribution with a large peak between 15 and 35 years of age Clinical management is focused on early recognition and resolution of severe attacks, achievement and maintenance of remission with medication, enhancement of patient quality of life, and reduction of CRC risk as cited by (Domagalski, 2017).
Laboratory Tests: CBC might show low hemoglobin and/or hematocrit levels, indicating anemia; WBC and platelet counts might be elevated; PT might be prolonged. Serum electrolytes and serum albumin levels will typically be decreased. Inflammatory markers (e.g., ESR, C-reactive protein) might be elevated. Peri-nuclear anti-neutrophil cytoplasmic antibodies with perinuclear staining (p-ANCA) are present in ~ 85% of patients with UC › Other Diagnostic Tests/Studies. Abdominal x-ray will show the extent of disease and exclude toxic mega-colon. Endoscopic procedures (e.g., flexible sigmoidoscopy, colonoscopy) with biopsy confirm the diagnosis and define the extent and severity of disease; leukocyte scanning can be used when severe disease prohibits endoscopy. Air-contrast barium enema in cases of mild to moderate UC show mucosal changes and complications. NR 509 week 2.
Treatment: is individualized and commonly includes amino-salicylates, glucocorticoids, tumor necrosis factor (TNF) inhibitors, immune modulators, antibiotics, and antidiarrheal drugs. It is important to assess the severity of the disease. Bed rest or restrictive activity can be recommended. Medications like amino-salicylates (e.g., sulfaSALAzine, mesalamine), TNF inhibitors (e.g., inFLIXimab), immune modulators (e.g., azaTHIOprine), and/or I.V. corticosteroids (e.g., prednisone and antidiarrheal agents like loperamide can be helpful for client. Will continue to monitor number of stools in other to evaluate the effectiveness of treatment. It is important to closely monitor electrolyte imbalance and replace nutritional Losses and Provide Optimum Fluid Volume/Electrolyte Balance. Low residue and high calorie diet is recommended. Client will be encouraged to seek dietitian consult to individualize the diet according to tolerance, preference, meal frequency, and food presentation to minimize anorexia. Client will be encouraged to take supplemental vitamins, calcium, potassium, and iron, as ordered. Evaluation of treatment response through monitoring of intake and output, vital signs, weight, and laboratory values as well as antibiotics may be ordered whenever infectious complications develop. Client will benefit from counseling on strategies for coping with a chronic disease and to a social worker for identification of local support groups. Client will be encouraged to keep stool diary to identify irritating foods. Health care provider will recommend nothing by mouth during exacerbation period.
Differential for Sinus Congestion
Sinusitis is an inflammation of one or more of the four paired para-nasal sinuses surrounding the eyes. It is extremely common but likely an over diagnosed condition, with more than 30 million Americans treated for acute sinusitis annually. Many patients with nasal and sinus symptoms have self-limited viral infections or allergic conditions; the physician must distinguish these patients from the patient with a bacterial infection who may require antibiotics. Although acute sinusitis is often self-limited, there is significant morbidity associated with sinusitis. The extension of infection into the central nervous system and bone may be life threatening. The normal sinuses have sterile structures lined with ciliated epithelium. Mucus is cleared from the sinus in a directed manner toward the Ostia, or openings, which drain into the nasal cavity at the superior meatus and middle meatus. The superior meatus drains the posterior ethmoid and sphenoid sinuses, and the middle meatus drains the frontal, maxillary, and anterior ethmoid sinuses. Occlusion of these ostio-meatal complexes can lead to dysfunction of the normal sinus epithelium and bacterial infection. Although any sinus can become occluded through viral infection, anatomic abnormalities (including septal deviation, tumors, and polyps) or allergies can also predispose one to infection NR 509 week 2.
Acute Sinusitis
The common cold is actually a rhino-sinusitis that frequently involves the para-nasal sinuses. Computed tomographic study of patients with the common cold as cited by (Aring, 2011). According to (Goroll, 2014) more than n 85% have a self-limited para-nasal sinusitis which can resolve without treatment. The maxillary sinuses are the most common sites (87%), followed by ethmoidal (65%), sphenoidal (39%), and frontal (32%) involvement. Rhinorrhea and nasal stuffiness are the typical symptoms. Although symptoms may persist for well more than 10 days, those of uncomplicated viral rhino-sinusitis usually start to improve by 7 to 10 days as cited by (Chow, 2012). Failure to improve suggests bacterial super infection. In about 0.5% to 2% of cases of the common cold, bacterial infection of the sinuses occurs, resulting in acute purulent bacterial sinusitis. It is characterized by nasal congestion, purulent nasal discharge, facial pain (which classically increases when the patient stoops forward), fever, fatigue, and other constitutional symptoms. Sinus pain or pressure and purulent nasal discharge are the defining clinical features of acute sinusitis. Maxillary sinusitis is the most common and produces pain and tenderness over the cheeks. The pain is referred to the teeth in some patients NR 509 week 2. Frontal sinusitis produces pain and tenderness over the lower forehead. Ethmoid sinusitis results in retro-orbital pain and may have tenderness over the upper lateral aspect of the nose. Isolated sphenoid sinusitis is uncommon but can present as retro-orbital, frontal, or facial pain. Purulent nasal discharge may be visualized in the middle meatus if the frontal, maxillary, or anterior ethmoid sinus is involved.
Laboratory work: Elevated erythrocyte sedimentation rate or C-reactive protein is useful in diagnosing sinusitis; however, it is not common practice to obtain these tests.
Treatment: Patients with mild acute sinusitis may respond sufficiently well to the treatments listed and will not require antibiotics. In more severe cases of acute purulent sinusitis, antibiotics are commonly used. Meta-analyses of earlier studies indicate some small advantage for antibiotics in clinical improvement at 7 days, at the expense of antibiotic side effects.
Decongestants are available in both topical and systemic preparations. The mixed adrenergic agonist pseudoephedrine is reasonably effective and can be administered by mouth. Popular sympathomimetic nasal sprays include phenylephrine (Neo-Synephrine) and oxymetazoline (Afrin), which is the longest acting of the topical decongestants. Patients should be instructed to spray each nostril once and then wait a minute to allow the anterior nasal mucosa to shrink. A repeat spray will then reach the upper and posterior mucosa, including the nasal turbinate’s and sinus Ostia. This procedure can be repeated as needed every 4 hours with phenylephrine and every 12 hours with oxymetazoline for up to 3 days. Tachyphylaxis and irritation develop with prolonged topical use, but risk is minimal with short-term administration (1 to 3 days). Non-pharmacologic treatment: Although large well-designed trials have not been conducted in acute sinusitis, the inhalation of steam or water and nasal irrigation with warm hypertonic saline appear to relieve symptoms of nasal congestion. Saline irrigation has improved airway patency, mucociliary clearance, and quality of life scores. A neti pot, which is a container designed for nasal irrigation, can be used several times a day NR 509 week 2.
Reference
Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam Physician 2011;83:1057. (A concise review of diagnosis and treatment, advocating watchful waiting for seven days, followed by narrow-spectrum antibiotics if there is no improvement.)
Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54:e72. (IDSA guideline that advocates only using antibiotics for patients with symptoms lasting more than 10 days or with severe symptoms for 3 days. Amoxicillin– clavulanate is recommended as the first-line treatment based on epidemiology of causative agents. NR 509 week 2)
Domagalski, J. E. (2017). Ulcerative colitis. In F. J. Domino (Ed.), The 5-minute clinical consult standard 2017 (25th ed., pp. 1078-1079). Philadelphia, PA: Wolters Kluwer.
Wanderer AA, Bernstein IL, Goodman DL, et al. The diagnosis and management of urticaria: a practice parameter. Ann Allergy Asthma Immunol 2000;85:521. (A practice parameter paper.) NR 509 week 2