Erin B. came for a visit to her doctor with complaints of fever, shakiness, weakness, nausea, and excessive vomiting. Additionally, she had a cough and palpitations, as well as reported losing her weight. Such information necessitates further investigation with the view to acquiring a full image of the present illness; HPI is pivotal as it can allow making the right diagnosis and developing an appropriate patient management plan. As such, healthcare providers should ask questions about the beginning of the illness, characteristics of the symptoms, and the exact data about when and where particular signs or symptoms began manifesting (Goolsby & Grubbs, 2015). Furthermore, they should question the patient about the factors that alleviated or worsened the symptoms, when they happened, and the severity of changes.
Other fundamental aspects of the HPI include diagnosing any associated symptoms (relevant negatives and positives), other pertinent ailments, previous diseases, diagnoses, or surgeries that can be connected to the current illness. In the case of this particular patient, her symptoms started showing some days after her flu. She cited no alleviating or aggravating trends in her symptoms and had not sought any treatment thus far. She described her fever as very severe and constant, as well as reported having recorded a temperature of 1010F. Other symptoms that were pertinent to the patient’s illness included exercise and heat intolerance, insomnia, oligomenorrhea, chest flutters, and bowel hyperactivity.
Ms. B.’s physical exam revealed aspects that require detailed analysis. For instance, the results of her vitals showed notable derangements from physiological ranges. She had a raised body temperature (380C), which indicated a fever, a high rate of respiration (20 breaths/minute), an elevated blood pressure (160/68 mmHg) that pointed to hypertension, and a pulse rate that was characteristic of tachycardia (150 beats per minute). Additionally, her systemic evaluation was another evidence of certain abnormalities in her body systems, including the cardiovascular, endocrine, psychiatric, and gastrointestinal ones.
The physical assessment of the patient brought several findings to light. Her enlarged thyroid gland with audible bruits and thrills was the most significant problem. The patient was underweight as her biometric index was 17.8. Besides, she complained of losing weight unintentionally. In addition, Ms. B. showed symptoms that were undoubtedly crucial for the establishment of the diagnosis. These signs included insomnia, tremors, nausea and vomiting, fever, anxiety, and oligomenorrhea. Additionally, the patient had bowel hyperactivity, tachypnea, hyperreflexia, tachycardia, palpitations, and an early systolic murmur. It is also apparent that the patient was hypertensive and had a cough. However, the importance of these symptoms in making the final diagnosis is unknown.
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In this case study, differential diagnosis consists of sepsis, drug intoxication, thyrotoxic crisis, and pneumonia. Considering that the patient was febrile and eosinophilic, as well as had a pulse rate that exceeded ninety beats per minute, septicemia was a likely diagnosis. On the other hand, Ms. B. was diaphoretic and had tachycardia and hyperthermia; these symptoms pointed to the drug intoxication with selective serotonin reuptake inhibitors, sympathomimetics, or anticholinergics. However, the thyrotoxic crisis and pneumonia are the lead points in the above list. The patient complained of heat intolerance, weight loss, weakness, palpitations, tachycardia, hyperreflexia, excessive sweating, emotional lability, and thyroid enlargement. As such, hyperthyroidism (thyroid storm) is another must-not-miss diagnosis. Furthermore, the patient had some other symptoms, including a cough, fever, nausea and vomiting, and dyspnea; they emphasized pneumonia as an important differential.
In terms of the test results and symptoms, Ms. B. experienced a thyrotoxic crisis. The outcomes of her thyroid function tests revealed low TSH titers and increased free T3 and free T4 levels. According to Fischbach and Dunning (2014), these results are indicative of primary hyperthyroidism. Despite being tested positive for Streptococcus pneumoniae, the x-ray images obtained from her chest revealed no signs of pathology. Additionally, toxicological studies on her blood samples gave negative results of the same, as well. Using the twelve-lead electrocardiogram, findings of abnormal heartbeats were made. Therefore, in this case, the final diagnosis is the thyrotoxic crisis.
A3 SOAP Note
|Name: E. B.||Pt. Encounter Number: FJ001/21/17|
|Date: 20th April 2017||Age: 22||Sex: Male|
“I have been having watery eyes and a stuffy nose for the last two weeks.”
The patient complains of recurrent sneezing, clear rhinorrhea, and nasal congestion, the onset of which was about two weeks ago. His eyes then got watery and itchy a week ago. He reports having a self-resolving sore throat on some days of the week. His symptoms are mostly worse early in the morning and late in the evening. The patient recalls that the symptoms started after a night out in a smoky pub. He additionally accounts to spending most of his time playing soccer. E.B. has a new friend, who smokes heavily, and his congestion tends to worsen just after being with this friend. He recalls having allergies during his childhood and reports receiving injections for the same. However, since being a teenager, the symptoms had not appeared until now.
TriSprentec for contraception;
Mucinex-D for the congestion;
Benadryl for the sneezing;
Ibuprofen prn for the pain.
Chronic Illnesses/Major traumas
Father – Diabetes, hyperlipidemia, and hypertension;
Mother – Pollen and bee-sting allergies;
Sister – Allergic to dust and smoke.
The patient is a full-time university student, who stays on campus in a dormitory room with a new roommate, who smokes heavily. He has a girlfriend, with whom he has sexual relationships and reports using condoms. The patient reports drinking at parties occasionally. However, the man denies smoking or abusing any other recreational drugs. His immunizations are up-to-date; he exercises regularly.
Patient denies any changes in his weight or appetite, chills, fever, fatigue, and night sweats.
E.B. denies having chest pains, PND, high blood pressure, missing beats, irregular pulse, edema, orthopnea, and palpitations.
He denies having any abnormalities, discolorations, rashes, easy bruising, or delayed healing.
E.B. has no cough, no history of lung infections, and hemoptysis; he does not wheeze.
The patient reports itchy and watery eyes bilaterally. However, he experiences no visual changes and blurring; he does not use any corrective lenses.
E.B. denies hematemesis, abdominal pain, nausea, vomiting, diarrhea, melena stool, heartburn, or constipation
The patient has no earaches, tinnitus, discharge, or hearing loss.
He reports no changes in the urine color, frequency, and urgency, no dysuria, hematuria, or burning. E.B. uses condoms for contraception and has no history of STIs.
The patient reports nasal drainage and congestion. However, he denies epistaxis, sinusitis, discharge, hoarseness, odynophagia, or dental diseases.
E.B. has no back pains, fracture history, joint pain, stiffness, and swelling.
He denies having bumps, lumps, and discolorations.
The patient reports no black-out spells, seizures, syncope, weakness, temporary paralysis, and paresthesia.
The patient is HIV negative, denies having any blood transfusions, swollen glands, night sweats, changes in hunger and thirst, and heat or cold intolerance.
E.B. has no history of anxiety, depression, sleep disorders, or suicidal ideations.
|Weight: 141 lbs. BMI: 22.8||Temperature 98.20F||BP 102/70 mmHg|
|Height: 5’6”||Pulse 86/minute||Resp 16 breaths/minute|
A neat, healthy-looking adult male in no acute distress. He is alert and oriented, as well as answers questions appropriately.
The skin is free of any lesions and rashes; it is dry, warm, clean, and intact with the normal turgor and elasticity.
Head: Lesion-free, non-tender, atraumatic, symmetric, and normocephalic. Slight pressure is recorded on palpating maxillary sinuses. Ears: Both canals are non-edematous, non-erythematous, and patent. The tympanic membranes are responsive to the light and are intact. Eyes: PERRLA, the sclera is anicteric, watery discharge, normal acuity, and intact extraocular muscles. Nose: edematous, boggy turbinates, nasal mucosa is mildly erythematous, and both nares appear filled with rhinorrhea. The nasal septum is in the proper positioning, and no creases are noted transversally. Throat: The oropharynx is non-erythematous and non-edematous. The mucosa is ulcer-free, moist, and pink. Neck: Flexible, non-tender with a full range of motion. The thyroid is nodule-free and non-enlarged, and no lymphadenopathy is observed.
Normal heart sounds with regular rhythm and rate are observed. No murmurs, gallops, rubs, or clicks are present. The extremities are non-edematous and well-perfused.
The chest wall is symmetric. Both lungs are clear to auscultation, and the respirations are unlabored.
The abdomen is non-distended, non-tender, and soft with active bowel sounds in all quadrants. Palpation reveals no organomegaly.
The breasts are non-tender, free from any discharge, wrinkles, discoloration, and masses.
The penile shaft is lesion-free, is correctly positioned with discharge-free urethral meatus. The testes and epididymis are palpable and lack any masses. The prostate is non-tender, smooth, and non-nodular.
The patient has a normal gait and stance, and all limbs have a full range of motion.
The patient has a clear speech and appropriate tone.
The patient is well-oriented in time and space, neatly dressed, and answers questions appropriately while maintaining eye contact.
Total blood eosinophil count – Eosinophilia;
Total serum immunoglobulin E – Increased serum IgE titers;
Fluorescence enzyme immunoassay – elevated IgE levels.
Magnetic resonance imaging, radiography, and computed tomography scanning (Sheikh, 2017).
|· Include at least three different diagnoses:
· Viral rhinosinusitis;
· Allergic rhinitis;
· Non-allergic rhinitis.
· Final diagnosis:
· Allergic rhinitis.
|PLAN including education|
· Further testing:
Allergy skin test.
Intranasal corticosteroid spray (Flonase);
Nasal saline spray.
The patient should stop using the decongestant as its effectiveness is only short-term. Additionally, he should adopt the use of Zyrtec for his allergy symptoms as it has no lag effects. Additionally, appropriate education on the use of nasal spray should be given. The patient should also avoid such triggers as smoke.
· Nonmedication treatment
Cleaning nasal canals with salty water upon congestion (WebMD, 2017).
The patient should keep records of exposure to allergens and report to the clinic as soon as he notices that his symptoms are unresponsive to drugs.