Nasal Congestion And Itching- Focused SOAP Note Paper

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: Nasal Congestion And Itching- Focused SOAP Note Paper

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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. Nasal Congestion And Itching- Focused SOAP Note Paper

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 7^th edition formatting.

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.

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.

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. Nasal Congestion And Itching- Focused SOAP Note Paper

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.

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). 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). 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 Nasal Congestion And Itching- Focused SOAP Note Paper

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

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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.
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 Nasal Congestion And Itching- Focused SOAP Note Paper