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Health, Medicine, Nursing
Case Study
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Focused SOAP Note Exemplar: Physical Exams and Diagnostic Tests (Case Study Sample)


Learning Objectives
Apply assessment skills to diagnose eye, ears, and throat conditions
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat
To prepare:
With regard to the case study you were assigned:
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.
You must use the document noted below an example is attached. You can choose any one of the presented cases.
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.


CC: Nasal Congestion and irritability
HPI: Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Patient-reported to have struggled with an itchy nose, eyes, palate, and ears for 5 days. He said that he first noticed the symptoms as he is playing with his grandson in their garden.
PMH: Richard's record states that he has a history of hypertension. Every day, he takes 30mg of Nifedipine XL and 50mg of Metropolol. He regularly watches her sugar levels by taking Low GI foods and those with whole wheat. He exercises daily. He was taking Mucinex OTC for the past two nights. Albeit patient says it only helps minimally.
SH: Negative for tobacco use and liquor consumption. Widowed
VS: BP 184/100; P 92; R 21; T 96.5; 02 94% Wt 220 lbs; Ht 64”
General: Ears and throat are red, showing signs of inflammation,
Cardiovascular--PMI is in the 4th inter-costal space near the midclavicular line. Auscultation results in innocent heart murmur, suggesting no problems with her cardiac functions.
Pulmonary— Bilateral percussion and auscultation also suggests that air pathway could have mucus. He has pale, boggy nasal mucosa with clear thin secretions and

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