Focused SOAP Note For Nasal Congestion And Itching
Focused SOAP Note For Nasal Congestion And Itching
Focused SOAP Note
Patient information
Patient initials: R.M Age: 50 Race: Caucasian Gender: male
S.
CC:” Nasal congestion and itching.”
HPI: R.M, a 50-year-old Caucasian man, presented to the clinic complaining of nasal congestion, sneezing, rhinorrhea, and post-nasal discharge. He also claimed to have experienced a 5-day itchy nose, eyes, and ears. The patient reported his symptoms worsening at night, prompting him to take OTC Mucinex for the past two nights to assist him in breathing comfortably while sleeping; nevertheless, this did not help as much. Denies headache, nausea, or vomiting Focused SOAP Note For Nasal Congestion And Itching.
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Medication: Mucinex 1200mg 1 tab P.O. bid to help loosen his congestion.
Allergies: Reported seasonal allergies
PMHX: No significant medical history was reported. No surgical history was reported.
Immunization: Up to date. He last received his COVID-19 vaccine on 15/3/2021.
Family history: No significant family history was reported.
Social history: R.M is a father of four children. He is employed full-time as an accountant in a retail company. He denies smoking but admits to drinking alcohol with his wife on occasion. He claimed that he goes to gymnastics every Saturday for a workout. He is financially secure and has insurance for his family. Moreover, he started wearing a seat belt and not using his phone while driving. The patient consumes a well-balanced diet high in vegetables and drinks plenty of fluids.
ROS
General: Negative for fevers, chills, and weight loss or gain
HEENT: negative for head trauma, reported red and itchy eye. Denies changes in vision or hearing. Reported having nasal congestion, rhinorrhea, and post nasal drainage.
Cardiovascular: No chest pain, dyspnea on exertion, peripheral edema, irregular heartbeats, palpitation. Reported paroxysmal nocturnal dyspnea.
Respiratory: Denies SOB, and chronic cough
G.I.: Denies decreased appetite, nausea, vomiting, diarrhea, heartburn, and frequent belching. Focused SOAP Note For Nasal Congestion And Itching
GU: Denies urination urgency and frequency. No discharge from the penis was reported. No history of STIs was reported.
Msk: No myalgias or arthralgia’s.
Psychiatric: Denies depression or anxiety. Reported issue with sleeping owing to the issue with nasal congestion.
Endocrine: Denies heat or cold intolerances
Skin: No rashes and bruits reported.
O.
PE
VTS: BP 130/66 left arm, sitting using a regular adult cuff. Wt.: 188 lb. Ht.: 5’6 T.: 37.3 RR: 18 P: 80 Sp02: 98%
General: A&Ox3 appear well nourished.
HEENT; normocephalic, eyes are reddish and itchy. Have a pale boggy nasal mucosa with clear thin secretion and an enlarged nasal turbinate. His tonsils are normal, but his throat is somewhat erythematous.
Cardiovascular: RRR, no murmur, S.I. and S2 are both normal, no carotid bruits.
Lungs: Clear to auscultation
Skin: normal in appearance, texture and temperature.
Abdomen: Symmetrical without distention. Bowel sounds are normative. No masses or splenomegaly were noted.
MSK: ROM intact. Normal gait and posture.
Neuro: Cranial nerve ii to xii intact. Gait and cerebellar function are normal.
Genital: Rectal sphincter tone s normal. No rectal masses were noted. Guaiac is negative.
A.
Lab test and result
Skin test to detect body reaction to pollen grains, cockroaches, mold, and other antigens. The result was positive for pollen grain. Radioallergosorbent testing (RAST) to detect specific IgE antibodies Focused SOAP Note For Nasal Congestion And Itching.
Diagnosis
Differential diagnosis
Allergic Rhinitis:
Allergic rhinitis is a nasal infection caused by the body’s overreaction to an allergen in the air. Common symptoms include sneezing, itching, and a runny nose. Allergic rhinitis can occur at any time of year and is not only caused by pollen but also by pets, mold, and smoke (Hoyte et al.,2018)Focused SOAP Note For Nasal Congestion And Itching. Considering the patient’s clinical presentation and diagnostic test findings that confirmed reaction to pollen grain, this is the most likely diagnosis for the client.
Non-allergic rhinitis
Non-allergic rhinitis (NAR) is a disorder that causes symptoms similar to allergic rhinitis (A.R.) but does not involve the presence of an allergen. NAR is a diagnosis of exclusion and is made after other causes of rhinitis have been ruled out (Meng et al.,2021). Common causes of NAR include environmental and occupational allergies, viral infections, and other autoimmune disorders. It is usually diagnosed in adults ages 18 to 50 but can also occur in children and older adults.
Common cold
This is an acute respiratory illness marked by mild coryzal features of rhinorrhea, nasal congestion, and sneezing. This condition frequently manifests as a plentiful and thin nasal discharge that eventually turns sticky and purulent (DeGeorge et al., 2019)Focused SOAP Note For Nasal Congestion And Itching. It is mainly associated with rhinovirus. It’s also characterized by fever and chronic cough that was evident for R.M.
Primary diagnoses: Allergic rhinitis
References
DeGeorge, K. C., Ring, D. J., & Dalrymple, S. N. (2019). Treatment of the common cold. American family physician, 100(5), 281-289.
Hoyte, F. C., & Nelson, H. S. (2018). Recent advances in allergic rhinitis. F1000Research, 7. https://doi.org/10.12688%2Ff1000research.15367.1
Meng, Y., Wang, C., & Zhang, L. (2021). Diagnosis and treatment of non-allergic rhinitis: focus on immunologic mechanisms. Expert Review of Clinical Immunology, 17(1), 51-62. https://doi.org/10.1080/1744666X.2020.1858804
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.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case. Focused SOAP Note For Nasal Congestion And Itching
With regard to the case study you were assigned:
• Review this week’s Learning Resources and consider the insights they provide.
• 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 five possible conditions that may be considered in a differential diagnosis for the patient.
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. 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.
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Case Study 1: Last Name Beginning A-M
is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the briAdge of his nose to press and rub there. He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous Focused SOAP Note For Nasal Congestion And Itching