Diagnosis And Treatment Of Local Allergic Rhinitis SOAP Note
Diagnosis And Treatment Of Local Allergic Rhinitis SOAP Note
Episodic/Focused SOAP Note Template
Patient Information:
Initials, R. S Age 50 years old Sex Male Race Africa American
SUBJECTIVE DATA.
CC: “Sneezing and nasal congestion.”
HPI: R. S is a 50-year-old African American male. Upon visiting the clinic, the client complains about sneezing, nasal congestion, rhinorrhea, and postnasal drainage. He also reveals struggling with itching eyes, palate, nose, and ears, which started 5 days ago. He reports Mucinex OTC, which he takes at night to enhance breathing as the relieving factor. However, the client denies any aggravating factors. He does not report any pain Diagnosis And Treatment Of Local Allergic Rhinitis SOAP Note.
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Current Medications: Mucinex OTC 1200/16 mg orally once daily, which is taken to improve breathing.
Allergies: NKA.
PMH: The client denies any medical condition or surgery.
Soc Hx: No information provided.
Fam Hx: Details not availed.
ROS:
GENERAL: Denies fever or weakness.
HEENT:
Head: Denies hair texture change.
Eyes: Reports itching eyes. Denies loss of vision.
Ears: Reports itching ears and palate.
Nose: The client reports itching nose, nasal congestion, sneezing postnasal drainage, and, rhinorrhea, and.
Throat: Denies enlarged tonsils.
SKIN: Denies skin dryness or cracking
CARDIOVASCULAR: Denies chest discomfort.
RESPIRATORY: Denies shortness of breath or asthma.
GASTROINTESTINAL: Denies constipation or diarrhea.
GENITOURINARY: Denies frequent urination.
NEUROLOGICAL: Denies weakness or dizziness.
MUSCULOSKELETAL: Denies decline in motion range.
HEMATOLOGIC: Denies bleeding or bruising.
LYMPHATICS: Denies swollen nodes.
PSYCHIATRIC: Denies insomnia or suicidal thoughts.
ENDOCRINOLOGIC: Denies changes in appetite.
ALLERGIES: Denies any allergy.
OBJECTIVE DATA.
Physical exam:
General: The client is a 50 years old African American male. He maintains an upright posture and eye contact throughout the interview. The client is well-groomed and presentable. His affect, judgment, and mood are good. He is alert and oriented.
Vital signs: T 98F; B/P-120/69; RR 23 beats per minute; Pulse Ox 98%; W 182lbs; H 5’9″
SKIN: No cracking or rashes seen.
HEENT: Hair is black and evenly distributed. The eyes are bilateral with accommodation at 3mm. No drainage is present on external auditory canals. The client is seen pressing and rubbing the bridges of his nose. A pale color was seen in the nasal mucosa with thin secretions. Enlargement in nasal turbinates was seen. No swollen tonsils were noted Diagnosis And Treatment Of Local Allergic Rhinitis SOAP Note.
Neck: Full range of motion of neck and shoulders was noted.
Chest/Lungs: Clear lungs on auscultation.
Heart/Peripheral Vascular: Normal S1 and S2 present.
Abdomen: No tenderness.
Genital/Rectal: Omitted
PV: Palpable peripheral pulses.
Musculoskeletal: Normal back curvature
Neurological: Motor is 5/5 throughout.
Psych: Good judgment and insight
Diagnostic results:
- Lab test for IgE antibodies was ordered: The results indicated the presence of allergen-specific IgE in the serum.
- Skin prick test: Awaiting results.
ASSESSMENT.
Differential Diagnoses
- Allergic rhinitis (AR)
- Non-allergic rhinitis
- Infectious rhinitis
- Nasal polyposis
- Nasopharyngeal carcinoma
The original diagnosis for this client is allergic rhinitis, which is a sub-category of chronic rhinitis. People with this condition mainly complain about sinus pressure, nasal congestion, itching in different parts, including the nose, mouth, eyes, or throat, post-nasal drainage, puffy/swollen eyelids, sneezing, rhinorrhea, and cough (Greiwe & Bernstein, 2019). The client has allergic rhinitis since has most of these symptoms such as sneezing, nasal congestion, rhinorrhea, postnasal drainage, and itching eyes, palate, nose, and ears.
Non-allergic rhinitis is the second differential diagnosis for this client. Its symptoms include nasal congestion, chronic sneezing, or a drippy nose (Terada & Kawata, 2022). Similarly, the client reported nasal congestion, sneezing, rhinorrhea, and postnasal drainage. He also reported itching nose, palate, eyes, and ears, indicating the likelihood of non-allergic rhinitis. Nonetheless, this condition is ruled out due to the absence of a drippy nose, which is a significant symptom of non-allergic rhinitis.
Infectious rhinitis is another potential diagnosis for this client. It is mainly characterized by sneezing, runny, stuffy, and itchy nose. People with this condition also report itching eyes, throat, and ears, nosebleeds, or clear nasal drainage (Liva et al., 2021). The client might have this condition since he reported nasal congestion, sneezing, rhinorrhea, postnasal drainage, and itchy nose, ears, eyes, and throat. However, this infectious rhinitis is ruled out due to the absence of significant symptoms, including nosebleeds, runny nose, and clear nasal drainage.
The client should also be diagnosed with nasal polyposis, which is characterized by a runny nose, persistent stuffiness, postnasal drip, reduced sense of smell, loss of taste, pain in the upper teeth, headache, facial pain or headache, or pressure over the face or forehead (Hopkins, 2019). The client might have this condition since he reported postnasal drip and nasal congestion. However, this condition is ruled out due to the absence of other vital signs such as runny nose, reduced sense of smell, loss of taste, pain in the upper teeth, headache, facial pain or headache, or pressure over the face or forehead.
The last differential diagnosis for this client is nasopharyngeal carcinoma. The most significant symptoms of this condition include a lump in the neck, blood in saliva, bloody nasal discharge, hearing loss, nasal congestion, sore throats, frequent ear infections, or headaches (Chen et al., 2019). The client reported nasal congestion, making this condition a potential diagnosis. However, this disease is ruled out due to the absence of vital symptoms such as a lump in the neck, blood in saliva, bloody nasal discharge, hearing loss, and sore throats.
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Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. 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. 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.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. 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.
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.
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.
By Day 6 of Week 5
Submit your Assignment.
Submission and Grading Information
To Prepare
A/B/C/D/E/F/G/H/I/J/K
CASE STUDY 1: Focused Nose Exam Richard 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 bridge 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 nas
‘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 Diagnosis And Treatment Of Local Allergic Rhinitis SOAP Note.
With regard to the case study you have selected:
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.
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.
References
Chen, Y. P., Chan, A. T., Le, Q. T., Blanchard, P., Sun, Y., & Ma, J. (2019). Nasopharyngeal carcinoma. The Lancet, 394(10192), 64-80. DOI:https://doi.org/10.1016/S0140-6736 (19)30956-0.
Greiwe, J. C., & Bernstein, J. A. (2019). Allergic and mixed rhinitis: diagnosis and natural evolution. Journal of Clinical Medicine, 8(11). Doi: 10.3390/jcm8112019.
Hopkins, C. (2019). Chronic rhinosinusitis with nasal polyps. New England Journal of Medicine, 381(1), 55-63. DOI: 10.1056/NEJMcp1800215
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/ 10.3390/jcm10143183.
Terada, T., & Kawata, R. (2022). Diagnosis and Treatment of Local Allergic Rhinitis. Pathogens, 11(1), 80. https://doi.org/10.3390/pathogens11010080
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Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “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 Diagnosis And Treatment Of Local Allergic Rhinitis SOAP Note:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Diagnosis And Treatment Of Local Allergic Rhinitis SOAP Note.