Subjective: What details did the patient provide regarding her personal and medical history? Objective: What observations did you make during the physical as
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?
SOAP #2 1
SOAP # 2: Allergic Rhinitis
Shumeka Hill, APN, PNP-AC
History & Physical Examination
SOAP #2 2
Patient Demographics: Name: J.V. Age/race/sex: 28 Hispanic Male Clinical site: Primary Care clinic
Chief Complaints : “My throat is scratchy, I’ve been sneezing non-stop, my nose has been running and congested, my eyes have been watery and itchy and I’ve been coughing for about two days now”.
History of Present Illness : Mr. V presents for a sick visit with scratchy throat, sneezing, non-productive cough, rhinorrhea with congestion, and itching, watery eyes for 48 hours. Patient denies any pain, fever, chills, body aches, SOB, n/v, or weight lost. Reports general malaise mostly from OTC cough and cold medicine. States cough is intermittent throughout the day but is worse upon waking. The patient has taken OTC Tylenol cold and allergy for moderate relief for about hours. Patient reports symptoms like this has occurred several times in the past but mostly during the spring and fall months or while cleaning his home or even while at work. During those time he was told his allergies had flared and he was given an OTC medication to use but he can’t remember which one it was. At this visit the patient hopes to receive something that will help subside his symptoms so that he can feel better right now but he also hopes to find something that can help to reduce the number of times he’s getting these allergy flares.
Past Medical History: Dust and Mold allergies that causes sneezing and coughing controlled with OTC
antihistamine. (can’t remember which one) Seasonal allergies-allergic-type-symptoms such as sneezing, water-itchy eyes,
nasal itchiness and discharge, and cough. Eczema controlled with daily lubricants and emollients. Last skin flare was about
three months ago.
Past Surgical History: No surgeries to date
Allergies: NKA to food or medications. Patient does report allergies seasonal allergies and allergies to dust and mold which causes allergic-type-symptoms listed in PMH.
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Medications: Tylenol cold with allergy relief 30mls every 8 hours as needed for symptom relief.
Health Maintenance: Patient receives annual flu shots. Last flu shot was given September 29th at CVS. All other immunizations are up-to-date including TDaP, MMR, and Varicella.
Personal & Social History: Lives in a single family home with his wife and young daughter, whose five years old. He owns a lawn care business and works about 6-7 days a week, he has a
dependable car and truck and is happy with his occupation. Denies any smoking or illicit drug abuse. Patient reports he is a casual drinker
and may have a shot or two at the bar on Fridays with his friends. Patient usually goes to the gym 3 days/week to do cardio and strength training.
However, he states he gets lots of exercise as well on his job. Patient is sexually active with only one sex partner, his wife. 24 hour diet recall: B- Banana, one piece of toast with peanut butter, and a cup of
milk; L-Steak Burrito with chips and salsa with a coconut water; Snack-one beef jerky and a cherry Jarrito; D-KFC (2 piece dark chicken thighs with corn on the cob, a biscuit, and a Mountain Dew)
Family History: Grandparents Paternal: Paternal grandfather 91, diabetes and Alzheimer’s disease; Paternal grandmother died at age 88 from complications of diabetes and obesity. Maternal: Maternal grandfather died on a boating accident at 58, maternal grandmother died at 82 from a stroke.
Parents Father: Father 68, alive and well with no health issues. Mother: Mother 65, alive. Has a history of asthma, allergies, and eczema.
Siblings Siblings: 1 older brother 37, alive and well; 1 younger sister 24 with asthma, in the army on active duty.
Children Children: 1 daughter, vaginal delivery, alive and well.
SOAP #2 4
Review of Systems:
General See HPI. Denies any fever, chills, night sweats, weight loss or weight gain in the past year.
Skin History of eczema, dry skin and itching. Denies abnormal lesions or new nevi/moles
Head Denies head injury, or masses, lesions and headache Eyes Reports clear, watery discharge and itchy. Denies any blurred
vision, vision loss or vision changes, eye pain or injection. Ears Reports bilateral ear itching and fullness. Denies vertigo, ear
pain or drainage or hearing loss or changes in hearing Nose/Sinuses Denies epistaxis, PND, maxillary or frontal sinus pain, or
changes in smell Mouth/Throat Denies sore throat and dysphagia. Denies gum disease, has
all original teeth, last dental exam was in January of this year, sees the dentist annually.
Neck/Lymph Nodes Denies swollen /painful lymph nodes, denies any neck pain or stiffness.
Testes Denies masses or pain, does not perform regular testicular exams.
See HPI. Denies any SOB, DOE, or wheezing.
CVS Denies CP, palpitations, denies peripheral edema, Orthopnea GI/Abdomen Denies dyspepsia, nausea, vomiting, diarrhea, constipation,
bloating, hematemesis, hematochezia, or abdominal pain. No recent changes in bowel habits.
GU Denies any pain on urination, frequency, urgency, or penile discharge.
Musculoskeletal Reports general malaise today. Denies arthralgia or myalgia. Neurologic Denies memory loss, paresthesia, and slurred speech, a
change in gait or imbalance. Endocrine Denies known glucose abnormalities, heat or cold intolerance Psychiatric Denies anxiety or depression.
OBJECTIVE Physical Examination:
Vital Signs/HT/WT T: 98.6F, P: 74 readily palpable, RR: 18, BP 118/68 on right, 118/70 on the left SaO2 on RA: 99% HT: 5’6”, WT: 145 (muscular-toned build, no change from baseline), BMI: 23.40,
SOAP #2 5
normal for ht. and wt. General 28 y/o Hispanic male, pleasant appears his stated age sitting
on the examination table in no distress as evidenced by relaxed extremities and unlabored breathing, well groomed, well developed, AAOx3
Skin Warm, moist, no rashes or suspicious moles, +turgor Head/Scalp ATNC, thick black hair, no dandruff, no lesions/masses. Eyes External examination without ptosis, strabismus or
exophthalmus. EOM intact. Swollen conjunctiva and sclera injection. Cornea clear. Iris without lesions, anterior chamber clear. PERRLA. Corneal reflex intact bilaterally, intact visual fields. Bilateral red reflex intact and symmetrical. No cataracts, hemorrhages or AV nicking.
Ears Auricles symmetrical, no lesions or tophi; External canal with mild erythema. TM translucent with cone of light intact, no bulging. Hearing intact with whisper, Weber midline, Rinne test: AC>BC bilaterally. Palpation without pre or post auricular lymphadenopathy
Nose Mild nasal crease. Bilateral nasal turbinates’ pale and boggy. Rhinorrhea present bilaterally with swollen mucosa. No foreign bodies, lesions, tumor, or purulence. Septum intact. No polyps CNI intact bilaterally.
Sinuses Transillumination of frontal and maxillary sinuses symmetrical without dullness. Non-tender to palpation and percussion, no drainage
Mouth Lips pink, moist mucous membrane, tongue midline w/o fissures. Gingiva without hypertrophy, retraction or bleeding. Teeth in good repair. CNXII intact, tongue protrudes in midline.
Pharynx/Throat Tonsils non tender, no exudates, Mild erythema noted to base of pharynx and no discomfort when asked to swallow.
Neck/Lymph nodes Trachea midline with brochial breath sound on ascultation, supple, no LAD, no Thyromegaly, Isthmus midline, no carotid bruit. Palpation without tenderness or masses. Carotid pulses 4/4 bilaterally. Full AROM without pain.
CVS RRR, normal S1, S2, no murmurs, rubs, or extra systole, JVD 3cm at 30 degrees, no carotid bruits, no cyanosis or vascular lesions. No chest wall deformity. PMI at 5th ICM MCL. Non- tender without heaves or thrill. Auscultation of the abdomen without bruit. Palpation without pulsatile masses
Lungs/Thorax Chest symmetrical without deformity, respirations even and unlabored throughout anterior and posterior lung fields. Palpation without tenderness. Tactile fremitus present. Resonance heard on percussion throughout anterior and posterior lung fields. Vesicular breath sounds auscultated throughout anterior and posterior peripheral lung fields.
SOAP #2 6
Abdomen Round, soft, non-tender, no palpable masses, non-tender to light and deep palpations x 4, no hepatosplenomegaly, liver span 10cm no CVA tenderness, BS + x 4 Q, no nausea or vomiting . Umbilicus midline. Last bowel movement this morning.
GU Bladder nonpalpable, kidneys nonpalpable rest of exam deferred
Musculoskeletal Mandible moves in midline TMJ palpation without clicks or tenderness. Neck and cervical spine have no noted deformities or signs of inflammation. Curvature of cervical, thoracic and lumbar spine within normal limits. Bony features of shoulders and hips are of equal height bilaterally and non- tender. Posture is upright and gait is smooth and normal. Palpation of spinous processes of C7-L5 are palpable, midline, and non-tender. AROM of all joints without any discomfort. No bony deformities, inflammation, or tenderness to joints or soft tissue of hands, wrists, fingers, shoulders, elbows, knees, ankles, feet, and toes.
Extremities/Pulses No edema/erythema, cyanosis or local tenderness to upper or lower extremities. Pulses 2 + at upper and lower extremities. Palpation warm to touch bilaterally.
Neurologic AA O X 3, no weakness, paresthesia, no aphasia/apraxia, gait and balance intact. CN II- XII intact. Memory and cognition intact for present and past medical history.
Psych Appropriate mood and affect
Evidence Based Assessment/Plan Clinical Decision Making: 28 y/o male presents with a two day history of rhinorrhea and congestion, sneezing, watery and itchy eyes, intermittent scratching sore throat, and intermittent paroxysmal non-productive cough consistent with Allergic Rhinitis given his recent exposure to dust and possibly mold after cleaning his basement. This has been an ongoing issue for him since he can remember with intermittent flares throughout the year. Given Mr. V’s presenting signs and symptoms there is a need to differentiate between the diagnosis of allergic rhinitis and acute sinusitis. Mr. V is an otherwise healthy young man with a history of multiple allergic flares throughout the year and eczema since birth. He has no other co-morbidities or health issues.
SOAP #2 7
CHARACTERISTICS OF DIFFERENTIAL DIAGNOSIS
SIGNS AND SYMPTOMS PHYSICAL EXAM FINDINGSi
Allergic Rhinitis Allergic rhinitis (AR) is a common yet under- appreciated inflammatory condition of the nasal mucosa, characterized by nasal pruritus, sneezing, rhinorrhea, and nasal congestion, the last of which is often deemed the most bothersome symptom. Frequently, there is associated palate, throat, ear, and eye itching as well as eye redness, puffiness, and watery discharge. AR is mediated by an IgE-associated response to ubiquitous indoor and/or outdoor environmental allergens.
Risk Factors include: Family history of atopy or other atopic conditions such as eczema, food allergies, and asthma/wheezing, age <20, exposure to indoor and outdoor allergens (American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO), 2017).
Diagnosis is usually based on clinical presentation.
Nasal congestion Sneezing Rhinorrhea (clear or
colored may exist, though colored rhinorrhea may indicate a co-morbid disease process with AR))
Itching of nose, eyes, palate
Post-nasal drip Frequent throat
clearing Cough Malaise (may be
presenting complaint in children)
Fatigue (may be presenting complaint in children) (American Academy of Otolaryngology- Head and Neck Surgery Foundation, 2017).
Clear rhinorrhea (clear or colored may exist, though colored rhinorrhea may indicate a co-morbid disease process with AR)
Bluish or pale swelling of nasal mucosa
Ocular findings (watery discharge, swollen conjunctivae, scleral injection)
Frequent throat clearing Allergic shiners Nasal crease Absence of foreign body,
tumor, purulence suggesting infection (American Academy of Otolaryngology-Head and Neck Surgery Foundation, 2017).
Acute Sinusitis Acute sinusitis, also called acute rhinosinusitis, is a short-term infection or
thick, yellow, or
Pain over the bridge of the nose may mean an infection in the
SOAP #2 8
inflammation of the membranes that line your sinuses. It prevents mucus from draining from your nose. According to the American Academy of Otarlaryngology (AAO, 2017), acute sinusitis is common, affecting more than 37 million Americans a year. (AAO, 2017).
Risk factors include: allergies or hay fever
nasal passage abnormalities, such as a deviated septum or nasal polyp
smoking or frequent breathing in of pollutants
a weakened immune system
Diagnosis is usually based on clinical presentation.
green mucus discharge from the nose
a cough (usually worse at night)
drainage of mucus in the back of your throat
pain, pressure, or tenderness behind your eyes, nose, cheeks, or forehead
reduced sense of smell
reduced sense of taste
Deep pain behind the eyes or headache in the back of the head may mean an infection in the sphenoidal sinuses.
Pain above the eyebrow in the morning that gets worse when bending over may mean an infection in the frontal sinuses.
Pain or pressure in the cheeks may mean an infection in the maxillary sinuses.
Thick discolored mucous coming from sinus opening.
Dullness of the light reflex with transllumination of maxillary or frontal sinuses.
Diagnosis 1-Guidelines for Treatment for Allergic Rhinitis: The treatment goal for allergic rhinitis is relief of symptoms. Therapeutic options available to achieve this goal include avoidance measures, oral antihistamines, intranasal corticosteroids, leukotriene receptor antagonists, and allergen immunotherapy. The newer, non-sedating, second-generation oral antihistamines (e.g.,
SOAP #2 9
desloratadine [Aerius], fexofenadine [Allegra] and loratadine [Claritin]) are the first-line pharmacological treatments recommended for all patients with allergic rhinitis. Intranasal corticosteroids are also first-line therapeutic options for patients with mild persistent or moderate/severe symptoms and they can be used alone or in combination with oral antihistamines. When used regularly and correctly, intranasal corticosteroids effectively reduce inflammation of the nasal mucosa and improve mucosal pathology. Other therapies that may be useful in select patients include decongestants and oral corticosteroids. Oral and intranasal decongestants (e.g., pseudoephedrine, phenylephrine) are useful for relieving nasal congestion in patients with allergic rhinitis. If the patient’s symptoms persist despite appropriate treatment, referral to an allergist should be considered (AAFP, 2010). Medications prescribed today;
Loratadine (Claritin)- 1 tablet (10 mg), once daily PO Fluticasone propionate (Flonase) – 2 sprays (50 µg/spray) EN, once daily or
every 12 hours X 1 week.
Diagnostic test needed: No further diagnostic test needed at this time. Diagnosis is based on clinical presentation and history.
If symptoms persists despite use of medications. Referral to allergists might be needed for Immunotherapy treatment and skin prick testing to identify specific allergens.
Immunotherapy may be recommended for people who don’t respond well to treatment with medications or who experience side effects from medications, who have allergen exposure that is unavoidable or who desire a more permanent solution to their allergies. Immunotherapy can be very effective in controlling allergic symptoms, but it doesn’t help the symptoms produced by nonallergic rhinitis (ACAAI, 2014)
Two types of immunotherapy are available: allergy shots and sublingual (under-the- tongue) tablets.
Allergy shots: A treatment program, which can take three to five years, consists of injections of a diluted allergy extract, administered frequently in increasing doses until a maintenance dose is reached. Then the injection schedule is changed so that the same dose is given with longer intervals between injections. Immunotherapy helps the body build resistance to the effects of the allergen, reduces the intensity of symptoms caused by allergen exposure and sometimes can actually make skin test reactions disappear. As resistance develops over several months, symptoms should improve (ACAAI, 2014).
SOAP #2 10
Sublingual tablets: This type of immunotherapy was approved by the Food and Drug Administration in 2014. Starting several months before allergy season begins, patients dissolve a tablet under the tongue daily. Treatment can continue for as long as three years. Only a few allergens (certain grass and ragweed pollens) can be treated now with this method, but it is a promising therapy for the future (ACAAI, 2014).
Patient Education :
Rinse your nose and sinuses with a salt water solution or use a salt water nasal spray daily or as needed. This will help thin the mucus in your nose and rinse away pollen and dirt. It will also help reduce swelling so you can breathe normally.
Reduce exposure to dust mites. Wash sheets and towels in hot water every week. Cover your pillows and mattresses with allergen-free covers. Limit the number of stuffed animals and soft toys your child has. Wash your child's toys in hot water regularly. Vacuum weekly and use a vacuum cleaner with an air filter. If possible, get rid of carpets and curtains. These collect dust and dust mites.
Reduce exposure to pollen. Keep windows and doors closed in your house and car. Stay inside when air pollution or the pollen count is high. Run your air conditioner on recycle, and change air filters often. Shower and wash your hair before bed every night to rinse away pollen.
Reduce exposure to pet dander. If possible, do not keep cats, dogs, birds, or other pets. If you do keep pets in your home, keep them out of bedrooms and carpeted rooms. Bathe them often.
Reduce exposure to mold. Do not spend time in basements. Choose artificial plants instead of live plants. Keep your home's humidity at less than 45%. Do not have ponds or standing water in your home or yard.
Do not smoke. Avoid others who smoke.
Cough suppressant, also called antitussive, such as dextromethorphan. This medicine decreases your reflex and sensitivity to cough. This medicine may be kept behind the pharmacy counter for purchase
Get plenty of rest and drink plenty of fluids.
Take all medications as prescribed.
Can take OTC oral decongestant such as Pseudoephedrine as prescribed on the back of the label but do not take for longer than 2 weeks due to side effects (i.e., agitation, insomnia, headache, palpitations)
Wash hands for 30 seconds with soap and water or an alcohol based hand scrub after coughing, sneezing, or wiping nose
SOAP #2 11
Diagnosis 2-Guidelines for Treatment for Eczema: Atopic dermatitis is a skin disease. When a person has this disease the skin becomes extremely itchy. Scratching leads to redness, swelling, cracking, “weeping” clear fluid, crusting, and scaling. Often, the skin gets worse (flares), and then it improves or clears up (remissions). Atopic dermatitis is the most common kind of eczema, a term that describes many kinds of skin problems. The goals in treating atopic dermatitis are to heal the skin and prevent flares. You should watch for changes in the skin to find out what treatments help the most. Treatments can include:
o Skin creams or ointments that control swelling and lower allergic reactions.
o Antibiotics to treat infections caused by bacteria.
o Antihistamines that make people sleepy to help stop nighttime scratching.
o Drugs that suppress the immune system.
Skin care that helps heal the skin and keep it healthy.
Avoiding things that cause an allergic reaction.
Diagnostic test needed: No further diagnostic test needed at this time. No current Eczema flare.
Referrals/Consults: Continue to use emollients and lubricants to affected areas as they persist. Consult a dermatologist is symptoms of Eczema worsen.
Patient Education :
SOAP #2 12
If you can identify the trigger(s) of your eczema, try to avoid it (them) as contact will make treatment more difficult.
Maintain your skin moisture levels by using emollients regularly to help stop your skin from drying out.
Consider using steroid preparations that can be bought from the pharmacy without a prescription.
When using steroid creams read the instructions carefully. Ensure you use the right amount. DO NOT apply to the face.
Avoid scratching itchy skin, which only worsens symptoms.
You should not get the smallpox vaccine if you have atopic dermatitis.
If your skin irritation has not cleared or has worsened after 7 days of treatment with a topical steroid consult your PCP or Dermatologists.
Allergies can generally not be prevented but allergic reactions can be. Once a person knows they are allergic to a certain substance, they can avoid contact with the allergen. Strategies for doing this include being in an air-conditioned environment during peak hay-fever season, avoiding certain foods, and eliminating dust mites and animal dander from the home. They can also control the allergy by reducing or eliminating the symptoms. Strategies include taking medication to counteract reactions or minimize symptoms and being immunized with allergy injection therapy (CDC, 2017).
Healthcare Maintenance/Recommendations :
Annual Influenza vaccine
The USPSTF also recommends high blood pressure, depression, and alcohol misuse screening in this age group. Screening for HIV, Syphilis, HBV, HCV, and STI screening and behavioral counseling is also recommended in all sexually active males in this age group. Although, Mr. V exercises regularly and maintains a healthy weight and BMI, he doesn’t have good eating habits. Therefore, I think it’s important to counsel him on
SOAP #2 13
healthful diet practices such as the DASH diet, which is high in grains, fruits, vegetables, and low in fat to help prevent co-morbidities later on.
Continue lubrication as needed for eczema. Follow up with PCP if symptoms worsen or if you develop fever or start to cough up blood. Call 911 if you have interactions from any of the prescribed medicine. Follow up with allergist for further testing and therapy if symptoms continue to persist despite the use of first-line medications.
American Academy of Otolaryngology-Head and Neck Surgery Foundation. (2017). History and Physical Findings in Allergic Rhinitis. Retrieved from: https://www.entnet.org/sites/default/files/uploads/PracticeManagement/Resources/_files /allergic-rhinitis-history-and-physical-findings.pdf
American Academy of Family Physicians. (2010). Retrieved from: http://www.aafp.org/afp/2010/0615/p1440.html
American College of Allergy, Asthma, and Immunology. (2014). Allergic Rhinitis. Retrieved from: http://acaai.org/allergies/types/hay-fever-rhinitis
Allery, Asthma, & Clinical Immunology Journal. (2011) Retrieved from: https://aacijournal.biomedcentral.com/articles/10.1186/1710-1492-7-S1-S3 https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/Allergies .html
Centers for Disease Control and Prevention. (2017). Allergies. Retrieved from: https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/Allergies
U.S. Preventive Services Task Force. (2017). Grade A and B Recommendations. https://www.uspreventiveservicestaskforce.org/Search
National Institute of Health. (2016). Atopic Dermatitis. Retrieved from: https://www.niams.nih.gov/health-topics/atopic-dermatitis
SOAP #2 14
Master of Science in Nursing PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
Episodic/Focus Note Template
Initials, Age, Sex, Race
CC (chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT "bad headache for 3 days”).
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
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