(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C

Soap Note #1 DX: Allergic Rhinitis

PATIENT INFORMATION

Name: Ms. JD

Age: 23-year-old

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: NKDA

Current Medications:

· Cetirizine 10mg/d

· Mucinex-D

PMH:

Immunizations: Tetanus.

Preventive Care: No history.

Surgical History: No history of surgery.

Family History: Father- alive, 60 years old, healthy.

Mother-alive, 54 years old, HTN, hyperlipidemia.

Sister-alive, 20 years old, Asthma.

Social History: Denies alcohol, tobacco or illicit drugs use. College student, lives alone in campus hostels. Physically active and occasionally does exercise.

Sexual Orientation: Active

Nutrition History: Eats balance diet but avoids excessive junk food.

Subjective Data:

Chief Complaint: “stuffy nose” that has lasted for two weeks.

Symptom analysis/HPI:

Ms. JD is a 23-year-old patient who presents with complaints of a stuffy nose, rhinorrhea, congestion and sneezing. She reports a spontaneous start of the symptoms that have remained consistent. Indicates no particular aggravating symptoms but reports higher severity of the symptoms in the morning. She complains of a sore throat and itchy eyes. She reports an all-day clear runny nose. She indicates consistent outdoor handball practice routine. She reports using Cetirizine and Mucinex-D which do not help. She denies vision or taste changes. She denies fever or chills. Denies diagnosis with allergies.

Review of Systems (ROS)

CONSTITUTIONAL: Denies change in weight, fatigue, fever, night sweats or chills. NEUROLOGIC: Denies seizure, numbness or blackout.

HEENT: HEAD: Denies headache. Eyes: Reports itchy eyes. Denies vision change. Ear: Denies hearing loss, pain or discharge. Nose: Admits stuffiness, nasal congestion and clear discharge. Denies nose bleeds. THROAT: Reports a sore throat.

RESPIRATORY: Patient denies breathing difficulties, cough, wheezing, TB, pneumonia.

CARDIOVASCULAR: No palpitations or chest pain. No edema, PND or orthopnea.

GASTROINTESTINAL: Denies nausea, abdominal pains, vomiting and diarrhea. Denies ulcers hx.

GENITOURINARY: Denies change in urine color, urgency and frequency. Regular menses cycle. Denies ovulation pain. Denies hematuria and dysuria.

MUSCULOSKELETAL: Denies back and joint pains or stiffness.

SKIN: No skin rashes or lesions.

Objective Data:

VITAL SIGNS: Temperature: 36.7 °C, Pulse: 78, BP: 119/87 mmHg, RR 20, PO2-97% on room air, Ht- 1.60m, Wt 67kg, BMI 26.

GENERAL APPREARANCE: Healthy appearing. Alert and oriented x 3. No acute distress. Well-groomed and responds appropriately.

NEUROLOGIC: Alert, oriented, posture erect, clear speech. gait. to person, place, and time.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses mild tenderness. Eyes: Bilateral conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No edema, no lesions, no haemorhage. Clear discharge. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Nose: Mild erythema of nasal mucosa which is paly and boggy, congested nares with rhinorrhea. No nasal crease. Throat: Posterior pharynx with no tonsillar edema, erythema or exudate. Uvula midline. Moist mucous membranes.

Neck: supple. No cervical or post auricular lymphadenopathy. No thyroid swelling or masses. Non tender

CARDIOVASCULAR: S1and S2. RRR w/o sound. Capillary refill in 2 sec. Pulse >3.

RESPIRATORY: Regular respiration. Thorax symmetrical. No increased respiratory effort. Breath sounds vesicular on auscultation.

GASTROINTESTINAL: No hepatosplenomegaly. Bowel sounds present in all four quadrants. no bruits over renal and aorta arteries. Soft, non-distended, non-tender abdomen with no palpation.

MUSKULOSKELETAL: Full motion range in all extremities.

INTEGUMENTARY: intact, no lesions or rashes.

ASSESSMENT:

Main Diagnosis

Allergic Rhinitis (ICD-10 code J30.8)

Allergic rhinitis is an inflammatory infection of the nasal mucosa characterized by nasal congestion, sneezing and rhinorrhea (Greiner et al., 2011). It is an inflammation of the interior nasal lining due to inhalation of an allergen that results in a runny nose, stuffy nose, itchy eyes and sore throat (Seidman et al., 2015).

Differential diagnosis:

· Viral Rhino Sinusitis

Characterized by headaches, sore throat, nasal congestion, fever and sneezing (Reintjes & Peterson, 2016). Patient denied headache or fever.

· Acute Conjunctivitis

Associated with red eye and mucopurulent discharge and at times lack of itching (Azari & Barney, 2013). Patient reported itchy eyes but with a clear discharge.

PLAN:

Labs and Diagnostic Test to be ordered:

· Skin prick testing

· Serum Immunoassay test

· Acoustic rhinometry

Pharmacological treatment:

· Fexofenadine 120mg daily oral dose (Bernstein, Schwartz & Bernstein, 2016).

· Fluticasone furoate 2 sprays (27.5 µg/spray) EN, once daily

Non-Pharmacologic treatment:

· Allergen avoidance.

· Allergen immunotherapy

Education

· Patient should be educated on the nature of the disease, probability of progression and the importance of treatment (Greiner et al., 2011).

· Education on safety concern of the medications.

· Information on potential side effects of the medications to reduce higher treatment expectations.

· Educate the patient on efficient nasal drug admission for effective drug compliance and treatment.

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