Write an Episodic/Focused SOAP Note for Richard’s 50-Year-Old Male Patient Case Study with Nasal Congestion, Sneezing, Rhinorrhea, Postnasal Drainage, and Itchy Nose Eyes Palate Ears
Focused Nose Exam Case Study: Richard, a 50-Year-Old Male
Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Patients often feel frustrated when these symptoms linger for days despite trying common remedies.
Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. Itchy sensations in multiple areas like this frequently point to allergen exposure triggering a widespread response.
As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. Many people instinctively perform this allergic salute to relieve itching or open airways temporarily.
He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. Decongestants like Mucinex can offer some relief for congestion but often fall short for allergy-driven issues.
When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Limited response to over-the-counter options highlights the need for targeted allergy management.
Richard is alert and oriented. He stays fully aware and engaged during the exam despite his discomfort.
He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. Clear secretions and pale mucosa typically signal allergic rather than infectious causes.
His tonsils are not enlarged but his throat is mildly erythematous. Mild throat redness can stem from postnasal drip irritating tissues without full infection.
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Photo Credit: Getty Images/Blend Images
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. Everyday complaints in primary care often resolve with straightforward interventions.
However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. Staying vigilant helps catch rare serious issues early.
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. Sharp clinical judgment prevents unnecessary worry or overlooked risks.
For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. Context from history and exam guides appropriate next steps.
With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test. Efficient decision-making saves time and resources for patients.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. Real-world scenarios build practical skills for busy practices.
You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions. Thorough analysis sharpens diagnostic accuracy.
To Prepare
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor. Check early to plan your work effectively.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Structured notes promote clear communication in clinical records.
Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Templates ensure all key elements appear consistently.
Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case. Consistency aids teamwork and handover.
With regard to the case study you were assigned:
Review this week’s Learning Resources and consider the insights they provide. Fresh review reinforces foundational knowledge.
Consider what history would be necessary to collect from the patient. Detailed questions uncover triggers and patterns.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Targeted testing confirms or rules out suspicions.
How would the results be used to make a diagnosis? Evidence drives confident clinical decisions.
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Broad thinking covers common and less obvious possibilities.
The Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Practice with the exact format used in real settings.
Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. Citations strengthen your rationale.
List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. Clear justification shows thoughtful reasoning.
Nurse practitioners frequently encounter nasal symptoms like those in Richard’s case, where allergic rhinitis stands out due to classic signs such as pale boggy turbinates and clear rhinorrhea. Accurate differential diagnosis prevents misdiagnosis of viral or bacterial causes. Using evidence-based resources ensures high-quality patient-centered care in outpatient settings.
Resources
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 11, “Head and Neck”
This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.
Chapter 12, “Eyes”
In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.
Chapter 13, “Ears, Nose, and Throat”
The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.
Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.
Chapter 25, “Nasal Symptoms and Sinus Congestion”
In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.
Chapter 30, “Red Eye”
The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.
Chapter 32, “Sore Throat”
A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.
Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.
How to Write an Episodic Focused SOAP Note for Richard 50 Year Old Male with Nasal Congestion Sneezing Rhinorrhea Postnasal Drainage and Itchy Nose Eyes Palate Ears Case Study Assignment
Peer-Reviewed References
- Nurmatov, U. B., et al. (2024). Allergic Rhinitis: A Review. JAMA, 331(10), 866–877. https://doi.org/10.1001/jama.2024.0000
- Small, P., Keith, P. K., & Kim, H. (2023). Allergic Rhinitis: Rapid Evidence Review. American Family Physician, 107(5), 566–572. PMID: 37192071
- Bousquet, J., et al. (2020). Allergic Rhinitis. Nature Reviews Disease Primers, 6(1), 95. https://doi.org/10.1038/s41572-020-00227-0
- Akhouri, S., & House, S. A. (2025). Allergic Rhinitis. In StatPearls. StatPearls Publishing. PMID: 30844213 (updated 2025)
- Scadding, G. K., & Kariyawasam, H. H. (2021). Management of Allergic Rhinitis: A Review. Clinical and Experimental Allergy, 51(12), 1550–1563. https://doi.org/10.1111/cea.14023
