Seasonal Allergic Rhinitis Case Study

Seasonal Allergic Rhinitis Case Study

Seasonal Rhinitis

Five Open-ended Questions to ask the client

Which is your most preferred language of communication?

Determining the most preferred language of communication with the client helps healthcare workers to get good medical histories within the purview of an effective therapeutic relationship. The use of appropriate language enables healthcare to obtain comprehensive medical history that helps in making an accurate diagnosis. Obtaining complete health history for this client is important in planning tailor-made care and enhancing adherence to medical regimens and health promotion initiatives (Rizzoli, 2017). Thus, healthcare professionals can make an accurate diagnosis, plan treatment, predict health outcomes of the patient, and plan for person-centered care. Seasonal Allergic Rhinitis Case Study

When did the symptoms start?

Understanding the onset of symptoms can help determine the associated risk factors and develop a functional diagnosis and care plan for a patient. For the 48-year old Caucasian woman presenting with a sore throat, information about its onset can be used to determine whether the disease is acute or chronic.

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How does the headache present?

The nature and presentation of the headache could help in making useful diagnosis for the patient. For instance, tension headache, migraine and cluster headache present differently and could be indications of different medical conditions. The difference between tension headache and migraine is that the latter presents with a throbbing quality pain that is worsened on exertion (Rizzoli, 2017). Tension headache pain, however, tends to be stable and chronic. Cluster headache can be differentiated from migraine because the pain in cluster headache occurs in a shorter duration and recurs after a few months, followed by remission.

What makes the headache and sore throat worse?

By understanding the conditions that worsen the situation, the healthcare providers conducting the physical exam and history taking can rule out other causes of the symptoms. For instance, seasonal rhinitis may be aggravated by cold weather, while asthmatic symptoms are usually worsened by exposure to allergens such as pollen and cat fur.

What steps have you taken to relieve the headache?

The assessment of the remedies by the patient to relieve pain can provide information about potential drug interactions.

Rationales for the Physical Exam Components Performed

The physical exam components of the patient in the case study help to rule out other diseases and provide a comprehensive medical history that facilitates the planning of patient care. Medical records play a significant role in medical and scientific research that aims to discover better diagnostic and therapeutic modalities for patients (Terada, 2019). For these studies’ results to be accurate, the documentation must be complete, and authentic and missing data could lead to erroneous findings, affecting the overall clinical outcomes for the patients. For medical histories to be compelling, they must be documented. Seasonal Allergic Rhinitis Case Study

Evidence-based Articles Discussing New Guidelines to Each diagnosis

Strep pharyngitis: the condition usually affects the tonsils, and the patient presents with fever and sore throat. Other clinical features are enlarged lymph cervical lymph nodes, headache, nausea, and vomiting. The patient in the case study presented with fever, sore throat and headache, but the diagnosis was ruled out following a negative strep screen test.

Infectious mononucleosis: the condition is caused by the Epstein-Barr virus and is common among young adults and teenagers. The diagnosis is unlikely as the patient is neither a teenager nor a young adult (Cameron et al., 2018). The condition commonly presents with swollen cervical lymph nodes and dysphagia, clinical features that were absent in the patient.

Seasonal allergic rhinitis: the condition is characterized by an inflammation of the nose following an immune reaction to specific allergens. The patient rears a cat whose fur presents a significant allergen (Nibhanipudi, 2015). Some of the common medical features of the disease are runny nose and other symptoms that present during particular times of the year. This is a likely primary diagnosis as the patient presents with a runny nose and seasonal symptoms and has significant environmental risk factors.

Barriers to Quality Healthcare

The two main barriers to quality healthcare the patient experiences as per the information provided in the interview are cultural and linguistic barriers. Communication is an essential tool that facilitates change and group cohesion in healthcare settings and nurse-led processes. Effective communication motivates patients by clarifying and informing them about their roles and expectations in the therapeutic relationship by breaking language barriers. Useful communication reduces misunderstanding by facilitating shared decisions and connecting the healthcare providers to their clients in healthcare settings.

How to Address Barriers to Improve Quality of Care, the Patient Receives

Effective communication tools that facilitate shared decision-making are a useful approach to addressing the barriers to communication and linguistic barriers in inpatient care. Shared decision-making has been shown to improve the quality of care and enhance the patient’s involvement in the treatment regimen. The tool is also essential in promoting patient-centered care by incorporating the views and values of the client. Shared decision-making care promotes quality care because it enables healthcare professionals to design management tailored towards clients’ needs with multi-morbidity. Seasonal Allergic Rhinitis Case Study

Lauren Mesa Case Study

DOB: 12/1/1972

A 48-year-old Caucasian female patient presents to the clinic complaining of headache and sore/burning throat (3/10; burning in quality). The patient reports having a fever of 100.6°F in the last 24 hours, which returned to normal after she took 1000 mg of acetaminophen. The patient has a history of seasonal allergies; however, she reports that they usually affect her in the spring, and they are never accompanied by fever. She does complain of coughing and sneezing. Her eyes and nasal passages are itchy as well. As it is now October, the patient is concerned that she may be getting the flu. The patient reports receiving a flu shot at work but thinks the shot may have exposed her to the flu virus. She takes no routine medications.

Review of her chart reveals that she was last seen 6 months ago for her annual well-woman exam; her Pap smear was normal and there were no other significant findings. She denies using tobacco or illicit drugs, and reports alcohol intake of two to three drinks per week. She lives alone with three cats.

For today’s visit: Review of Systems (ROS) is positive for sore throat and mild headache. She also states that when she first began sneezing, the nasal discharge was clear but now it is thick and greenish-yellow in color.

PMH:

• Other active problems: infectious mononucleosis at age 18; seasonal allergies (typically worse in the spring)
• Medical, surgical, obstetric, hospitalizations: No history of hospitalizations

Rx (medications)/allergies:

• Rx (medications: Tylenol on occasion; takes OTC allergy medications (antihistamines) during the spring
• Allergies: Penicillin; seasonal allergies; no food allergies

Preventive health

• Preventive health: well-woman exam 6 months ago: Pap smear normal; mammogram normal; Blood chemistry: lipid profile (normal); fasting blood sugar (normal) and glycated hemoglobin (HBA1C) [normal].
• Immunizations: flu shot 2 months ago; last Tdap 2 years ago.

FHx/SHx:

• FHX (family history): Father is still living; no significant health problems; mother has hypertension
• SHS (social history)
• Occupation: English teacher
• Living situation: lives alone in a condominium with 3 cats
• Alcohol use: 2 to 3 glasses of wine/week
• Tobacco use: None – ever
• Illicit drugs: none/never
• Sexual history: sexually active; uses contraception (diaphragm)
• Diet: regular diet; tries to avoid sweets, but “cheats” about once a week
• Exercise: walks three times a week for 30 minutes

ROS (from patient interview):

• General/constitutional: No sleep concerns – usually gets 7 hours of sleep nightly; weight stable; a little tired
• Skin/breast: No skin complaints
• HEENT & Neck: Seasonal allergies common in spring; sore/burning throat (rated 3/10; burning in quality); mild headache (2/10); itchy eyes and nasal passages
• Cardiovascular: No concerns
• Respiratory: Intermittent coughing and sneezing; nasal discharge has turned from clear to thick and greenish yellow in color. Has tried Afrin nasal spray with little relief.
• Abdomen/gastrointestinal: No concerns; last BM this morning (usually daily) Seasonal Allergic Rhinitis Case Study
• Genitourinary: LNMP 2 weeks ago
• Musculoskeletal: No concerns
• Neurological: No concerns
• Allergic/Immunologic: fever of 100.6°F in the last 24 hours, which returned to normal after she took 1000 mg of acetaminophen.
• Lymphatic/endocrine: No swollen or tender lymph nodes
• Hematologic: No history of anemia
• Psychological: No history of depression or anxiety
  

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Physical Exam:

• General:
• Skin/breast: No pallor, jaundice, ecchymoses or rash
• HEENT &Neck: PERRLA. Thyroid WNL to palpation. Good dentition. Good dentition; erythematous posterior pharynx; no oral ulcers; nasal mucosa is erythematous and friable; sinuses tender; eyes are watery with clear discharge; neck supple with full range of motion. Strep screen negative (rule out pharyngitis)
• Cardiovascular: No jugular venous distension; Point of maximal impulse (PMI) 5th intercostal space (ICS); regular heart rhythm, no murmur; 3+ peripheral pulses; capillary refill less than 2 seconds; no peripheral edema
• Respiratory: Lung fields clear to auscultation and percussion
• Abdomen/gastrointestinal: Abdomen soft and nondistended. No hepatosplenomegaly. Bowel sounds present in all quadrants
• Genitourinary: Deferred
• Musculoskeletal: Normal strength
• Neurological: CN II – XII intact; DTRs +2
• Psychological: Not examined
• Allergic/Immunologic: Seasonal allergies
• Lymphatic/endocrine: No lymphadenopathy
• Hematologic: Not examined

Wk 7 Assignment Instructions

NRP/555: Adult And Geriatric Management I

Evidence-Based Practice Case Study Episodic SOAP Note/Reflection: Lauren Mesa Part 2

Now that you have completed your SOAP Note for Lauren Mesa (see attached), it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives.

Review the Lauren Mesa case study (see attached).

Write a minimum of a 700-word reflection providing rationale for your completed SOAP Note (see attached). Consider the interview information provided in the patient scenario. Include the following in your reflection:

• List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.
• Provide a minimum of 3 rationales for the physical exam components performed.
• Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each Provide a brief summary of the article(s) in your reflection.
• Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions, etc.).
• As the FNP, explain how you can address these barriers to improve the quality of care the patient receives. Use a minimum of 2 peer reviewed articles to support your answers.
• Use a minimum of 3 scholarly peer reviewed references. These references cannot be more than 5 years old.
• Cite and list your references according to 7th edition APA guidelines. Attach the references page to your SOAP Note.

References

Cameron, A., Akilan, K., & Carr, D. (2018). Infectious mononucleosis – not always a benign condition: a case report of contagious mononucleosis–associated acute acalculous cholecystitis. CJEM, 21(1), 154-156. https://doi.org/10.1017/cem.2018.15

Nibhanipudi, K. (2015). The usefulness of Leukocyte Esterase Test versus Rapid Strep Test for Diagnosis of Acute Strep Pharyngitis. Global Pediatric Health, 2, 2333794X1559915. https://doi.org/10.1177/2333794×15599156

Terada, N. (2019). Seasonal allergic rhinitis: impact of the disease and considerations for its management. Clinical & Experimental Allergy Reviews, 10(1), 35-38. https://doi.org/10.1111/j.1472-9733.2010.01153.x Seasonal Allergic Rhinitis Case Study

Rizzoli, P. (2017). Tension-Type Headache: Epidemiology, Diagnosis, and Pathophysiology. Deckermed Pain Management. https://doi.org/10.2310/pm.6815

See attached documents as well as info below. Now that you have completed your SOAP Note for Lauren Mesa (see attached), it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives. Review the Lauren Mesa case study (see attached). Write a minimum of a 700-word reflection providing rationale for your completed SOAP Note (see attached). Consider the interview information provided in the patient scenario. Include the following in your reflection: • List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint. • Provide a minimum of 3 rationales for the physical exam components performed. • Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s) in your reflection. • Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions, etc.). • As the FNP, explain how you can address these barriers to improve the quality of care the patient receives. Use a minimum of 2 peer reviewed articles to support your answers. • Use a minimum of 3 scholarly peer reviewed references. These references cannot be more than 5 years old. • Cite and list your references according to 7th edition APA guidelines. Attach the references page to your SOAP Note.  Seasonal Allergic Rhinitis Case Study