Discussion: Assessing the Ears, Nose, and Throat
As Motomura et al. (2016) point out, “pale nasal mucosa is a typical clinical finding in subjects with severe allergic rhinitis” (p. 220). In the case of Richard, the 50 year old male who has presented with nasal congestion, sneezing, rhinorrhea, and postnasal drainage—in other words, an itchy nose, eyes, palate and ears which have bothered him for 5 days—the symptoms that Richard is exhibiting are very likely the effect of severe allergic rhinitis or what is commonly known as hay fever.
As hay fever routinely occurs in the summer and spring months when pollen and mold are in the air and can be highly concentrated in areas depending on geography and weather, it is important to take note of external factors—the environment—that might be impacting Richard over the past week. A history of his outdoor activities, where he lives, whether he has been exposed to pollen or mold, to which his body could be having an exaggerated reaction should all be information that the nurse obtains over the course of questioning.
Quillen and Feller (2006) state that “allergic rhinitis, the most common type of rhinitis, generally can be differentiated from the numerous types of nonallergic rhinitis through a thorough history and physical...
1583). The history of the patient should therefore be obtained and a physical examination of eyes, ears, nose, throat, chest and skin should be conducted.
The diagnosis for the patient is severe allergic rhinitis and this can be confirmed through allergen testing. The physical examination leads to this supposition. Differential diagnoses include: non-allergic rhinitis, acute sinusitis, and deviated septum. Examination and testing for pathogens and/or bacterial infection along with nasal passage should be conducted. Information about the patient’s background, Soc Hx, and Fam Hx is needed. Questions to ask the patient include: Have you been outdoors recently, walking, hiking, gardening, etc? What is your workplace environment like? Do you have a history of allergies popping up at this time of the year? Are allergies in your family? What are you lifestyle habits? Have you been taking any recreational drugs?
Episodic/Focused SOAP Note
Patient Information: R. 50 M N/A
S.
CC (chief complaint): “itchy eyes, nose, throat, ears for 5 days”
HPI: 50 year old R male
Location: head
Onset: 5 days ago
Character: itchiness in eyes, nose, throat and ears
Associated signs and symptoms: pale, boggy nasal…
