86%(7)6 out of 7 people found this document helpful
This preview shows page 2 - 5 out of 5 pages.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physicalexam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
VS: 135/70; P89; R24; T 98.1; )2Sat 98% Wt: 185; Ht68”General: Patient looked tiredEyes: dark circles under the eyes; mild edema and erythema on the eyelidsEars: Nose: pale, boggy mucosa with clear thin secretions and enlarged nasal turbinatesThroat: tonsils are not enlarged but throat is mildly erymatousLungs: clear in all quadrants upon auscultationDiagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)1.)Anterior Rhinoscopy – nose is examined-reddened mucosa suggest inflammation-pallor and edema suggest allergy-pale, boggy mucosa; rhinorrhea with clear, watery mucus suggest allergic rhinitis (Dains, Baumann and Scheibel, 2016)2.)CBC (eosinophil count)- elevated IgE level and increased eosinophil level may be present in allergic rhinitis (Shelkh, 2018)- aeroallergens causes an IgE mediated reaction in allergic rhinitis (Lakhani, North and Ellis, 2012)- eosinophilia – blood or nasal discharge with seasonal allergic rhinitis 3.) Screening allergy skin test – if patient does not respond to H. blocking antihistamine and topical corticosteroids, move on to more specialized diagnostic imaging such as CT scan or MRI 4.) Cultures of nasal discharge - to r/o bacterial sinusitis – late complication
Differential Diagnoses :1.)Allergic Rhinitis – based on the patient’s presenting symptoms.