Soap Note

QUESTION

Use the Episodic/Focused SOAP Template and 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.

For this assignment, there will be information that you will need to make up to complete the entire soap note. Please use the soap note exemplar example as a guide. I think it is important to document a detailed HEENT exam and HEENT ROS for this assignment. It is also important to document a heart and lung exam on each patient. For the Subjective Data (document constitutional/general ROS) on all patients as well as Psych. Please use your clinical guide to documentation textbook as a guide as needed for documentation purposes.

Using the Episodic/Focused SOAP Template: · Documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. ·  Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.

A 28-year-old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte 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.

ANSWER

The patient, a 28-year-old female, presents with complaints of a runny nose and itchy eyes. She reports experiencing these symptoms approximately nine days ago, which coincides with the onset of spring. The patient states that this is a recurring issue for her during the spring season, lasting for about six to eight weeks. She describes her nose as continuously runny with clear mucus and experiences intermittent sneezing throughout the day. Additionally, the patient complains of intense itching in her eyes and occasional tickling sensation in her throat. She also mentions that her ears feel full and sometimes pop. The patient notes that she had taken Claritin last year, which provided relief. The patient appears alert and oriented during the assessment.

Objective

Upon examination, the patient’s nasal mucosa appears pale and boggy, with clear thin secretions. Enlarged nasal turbinates are observed, causing partial obstruction of the airway flow. However, lung auscultation reveals clear breath sounds. The tonsils are not enlarged, but the throat appears mildly erythematous.

Assessment

Based on the patient’s history and clinical presentation, the most likely diagnosis is allergic rhinitis. The patient’s symptoms, including persistent runny nose, itching eyes, and seasonal recurrence, align with allergic rhinitis, which is commonly triggered by environmental allergens such as pollen during springtime. The physical examination findings, such as pale and boggy nasal mucosa and enlarged nasal turbinates, further support this diagnosis.

Differential Diagnosis

Allergic Rhinitis: This is the most likely diagnosis considering the patient’s symptoms, seasonal recurrence, and physical examination findings. Allergic rhinitis is characterized by nasal congestion, runny nose, sneezing, and itching due to an allergic response to environmental allergens.

Non-Allergic Rhinitis: Although less likely given the patient’s seasonal recurrence, non-allergic rhinitis can also present with similar symptoms, such as a runny nose and nasal congestion. However, it is not triggered by allergens but can be caused by irritants, infections, or hormonal factors.

Acute Sinusitis: While sinusitis may present with similar symptoms such as nasal congestion and postnasal drip, the absence of facial pain or pressure makes it less likely in this case.

Viral Upper Respiratory Infection (Common Cold): While a viral infection can cause nasal symptoms and throat irritation, the duration and seasonal recurrence of the patient’s symptoms make this less likely.

Conjunctivitis: Itchy and red eyes can also be attributed to conjunctivitis. However, the patient’s nasal symptoms and history of seasonal recurrence suggest allergic rhinitis as the primary diagnosis.

Diagnostic Tests

To confirm the diagnosis of allergic rhinitis, the following diagnostic tests may be considered:

 Allergy Testing: Allergy testing, such as skin prick testing or specific IgE blood tests, can help identify specific allergens responsible for the patient’s symptoms. This information can guide allergen avoidance strategies and inform targeted treatment options.

Complete Blood Count (CBC): A CBC may be ordered to evaluate for any systemic inflammation or infection that could contribute to the patient’s symptoms.

Nasal Endoscopy: In cases where the diagnosis is uncertain or if there are concerns about other nasal pathologies, a nasal endoscopy may be performed to visualize the nasal cavity and assess for structural abnormalities or signs of chronic inflammation.

Pulmonary Function Tests (PFTs): PFTs may be considered in patients with suspected asthma or when the patient’s symptoms are not well-controlled with initial treatment measures.

Rhinoscopy: Rhinoscopy allows direct visualization of the nasal cavity and can help evaluate for any nasal abnormalities, such as nasal polyps, which may contribute to the patient’s symptoms.

Conclusion

Based on the patient’s history, symptoms, and physical examination findings, the most likely diagnosis is allergic rhinitis. Further diagnostic tests, such as allergy testing and nasal endoscopy, may be considered to confirm the diagnosis and guide appropriate treatment strategies. Timely and accurate diagnosis is essential to provide effective symptom relief and improve the patient’s quality of life.