SOAP Note for a Patient

Episodic/Focused SOAP Note

Patient Information

C., 28 years, Female, Caucasian

S.

CC (chief complaint): Runny nose and itchy eyes.

HPI: 28-year-old Caucasian female experiences a runny nose and itchy eyes every spring. The symptoms usually last between six and eight weeks. Current episode has lasted for 9 days and characterized by on and off sneezing and a tickle on the throat. Claritin gives her relief but does not make her completely better. Symptom severity is 7/10 pain scale.

Current Medications: None.

Allergies: No known allergies.

PMHx: No previous hospitalizations for any ear, nose and throat disorders. No trauma or surgeries to date. The patient is up-to-date on immunizations with the last tetanus immunization on 02/2022.

Soc Hx: Patient was born and raised in Hoboken, NJ. She lives with her husband and works as a Sales Manager at a local retail store. Her home and workplace has a working smoke detector. While she drinks alcohol and smokes at least twice a week, she exercises regularly.

Fam Hx: Her father, aged 55 has no significant medical history while her mother, aged 47 has a history of hypertension. Her two siblings have no significant medical history. Her maternal grandmother died aged 76 with a history of hypertension and her paternal grandfather dies aged 82 with a history of Type II diabetes. Her paternal grandmother and maternal grandfather are still alive with a history of high blood pressure and Type II diabetes respectively. The rest of her family members like uncles and aunts have no significant medical history.

ROS:

GENERAL:  Alert and oriented; no fever; no weakness, fatigue, weight gain or loss, denies any change in appetite.

HEENT:  Eyes: Itchy eyes; denies visual loss or blurred vision. Ears, Nose, Throat:  Ears feel full; denies hearing loss; sneezing (on and off); runny nose; a tickle on the throat.

SKIN:  No rashes; no changes in skin; no skin erythema or any other abnormalities.

CARDIOVASCULAR: Denies chest discomfort or pain. No heart problems or edema.

RESPIRATORY:  No cough; no shortness of breath, no sputum.

GASTROINTESTINAL:  No reports of constipation, vomiting, or diarrhea. Denies abdominal pain.

GENITOURINARY:  Denies burning on urination. Last menstrual period, 02/28/2022.

NEUROLOGICAL:  Denies change in bladder or bowel control. No headaches; no tremors; no weakness.

MUSCULOSKELETAL: No join swelling or pain; no muscle pain, back pain or stiffness.

HEMATOLOGIC:  Denies bleeding, abnormal bruising, or getting sick easily.

LYMPHATICS:  Reports no enlarged nodes or history of splenectomy.

PSYCHIATRIC:  No mental stress; no depression; no anxiety; no mood changes. Denies sleep disturbances.

ENDOCRINOLOGIC:  Reports heat intolerance.

ALLERGIES:  Denies history of rhinitis, asthma, eczema or hives.

O.

Vital Signs: Blood pressure 125/80 (sitting), Temp 97 (oral), Respiratory Rate 22 breaths per min, Pulse 76bpm, Body Mass Index 22.2, Wt 173.5 pounds, Ht 63”, HR 90.

Physical Exam:

CONSTITUTIONAL: The patient is well developed and appropriately dressed and walked into the physician’s with no signs of distress and without any help. She seems to be in a good mood though sneezing at times.

HEENT:

i. Head: Non-tender, atraumatic, and symmetric. No hair loss, lesion or mass.

ii. Eyes: They appear red. No discharge noted; no edema; no lesions on eyelids.

iii. Ears: No edema, erythema, exudate in bilateral external ear canals.

iv. Nose: Pale, boggy nasal mucosa; enlarged nasal turbinates; runny with clear mucus.

v. Throat/mouth: Mildly erythematous.

PULMONARY: No dyspnea; no difficulty in breathing; wheezing.

CARDIOVASCULAR: No murmur, rub or gallop; no masses; regular heart beat rhythm; no heaves or thrills.

ABDOMEN: Abdomen symmetrical, flat, soft and with no distension. Bowel sound present and normal. No skin abnormalities.

MUSCULOSKELETAL: Patient alert and fully oriented. She can move all extremities without any pain. Her reflexes are symmetrical and no signs of joint swelling or weakness.

Lab/Diagnostic Test Results: (all lab tests done at the patient’s PCP office on 03/01/2022)

a. WBC: Hct 38.0, Blood glucose 102 mg/dL, 12,350 Hgb; Rectic 1.3 Diff Na, Troponin 24; ALT 25 IU/L, Alk phosphate 153 IU/L.

b. EKG: NSR 93, sporadic unifocal VPC’s; MB fraction positive.

A.

1. Allergic rhinitis (hay fever) due to runny nose, sneezing, nasal congestion, itchy nose, eyes, and throat and ear fullness (Small, Keith & Kim, 2018). This condition is essentially an allergic reaction to tiny particles in the air and can last several weeks on longer. The patient’s symptoms are the classic signs of this condition and are seasonal i.e. during spring.

2. No other significant health problems or concerns.

Differential Diagnoses

· Chronic rhinosinusitis. According to Wheatley & Togias (2015), allergic chronic rhinosinusitis is one of the differential diagnoses of allergic rhinitis. The patient could be diagnosed with allergic chronic rhinosinusitis because of nasal congestion and nasal drainage that last for at least 12 weeks every spring.