Allergic Rhinitis SOAP Note: Episodic Clinical Case Study
This paper presents an episodic, focused SOAP note for a 28-year-old Caucasian female presenting with recurrent spring-season runny nose, itchy eyes, sneezing, and throat irritation. The subjective section details her chief complaint, medical and social history, and a comprehensive review of systems. The objective section documents vital signs and physical examination findings, including pale boggy nasal mucosa and erythematous eyes. The assessment identifies allergic rhinitis (hay fever) as the primary diagnosis, supported by classic seasonal symptom patterns. Five differential diagnoses—chronic rhinosinusitis, seasonal rhinitis, perennial rhinitis, irritant rhinitis, and infective rhinitis—are considered and clinically justified with reference to peer-reviewed literature.
- Patient Information and Chief Complaint: Demographics, HPI, history, and social background
- Review of Systems: Multi-system symptom review findings
- Objective Findings and Physical Examination: Vital signs, physical exam, and lab results
- Assessment and Primary Diagnosis: Allergic rhinitis identified as primary diagnosis
- Differential Diagnoses: Five alternative diagnoses with clinical rationale
- References: Peer-reviewed sources cited in paper
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What makes this paper effective
- The SOAP format is followed rigorously, with each section (Subjective, Objective, Assessment, Plan) presenting organized, clinically relevant information in the conventional order expected in primary care documentation.
- The differential diagnoses section is well-supported by peer-reviewed citations, with each alternative diagnosis linked to specific patient symptoms and clinical reasoning rather than listed generically.
- The review of systems is comprehensive and systematic, covering over a dozen body systems and using appropriate clinical language to confirm or deny findings.
Key academic technique demonstrated
This paper demonstrates evidence-based clinical reasoning: the student does not simply name alternative diagnoses but explains why each differential applies to this specific patient by connecting symptom presentation to published diagnostic criteria. Citations from peer-reviewed journals such as the New England Journal of Medicine and American Family Physician ground the assessment in authoritative medical literature.
Structure breakdown
The paper opens with patient demographics and moves through the standard SOAP sequence: a detailed subjective section (HPI, medications, allergies, past and family/social history, and ROS), an objective section (vital signs, physical exam findings, and lab results), an assessment naming the primary diagnosis, and a differential diagnoses list. A references section closes the paper. The structure mirrors real clinical documentation practice, making it a strong model for healthcare students learning to write patient notes.
Patient Information and Chief Complaint
Patient: C., 28 years, Female, Caucasian
CC (Chief Complaint): Runny nose and itchy eyes.
HPI: A 28-year-old Caucasian female presents with a runny nose and itchy eyes that recur every spring. The symptoms usually last between six and eight weeks. The current episode has lasted nine days and is characterized by intermittent sneezing and a tickle in the throat. Claritin provides some relief but does not resolve symptoms completely. Symptom severity is rated 7/10 on the pain scale.
Current Medications: None.
Allergies: No known allergies.
PMHx: No previous hospitalizations for any ear, nose, or throat disorders. No trauma or surgeries to date. The patient is up-to-date on immunizations, with the last tetanus immunization administered in February 2022.
Social History: The 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 have working smoke detectors. She drinks alcohol and smokes at least twice a week but exercises regularly.
Family History: 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 at age 76 with a history of hypertension, and her paternal grandfather died at age 82 with a history of Type II diabetes. Her paternal grandmother and maternal grandfather are still alive with histories of high blood pressure and Type II diabetes, respectively. Other family members, including aunts and uncles, have no significant medical history.
Review of Systems
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; intermittent sneezing; runny nose; tickle in the throat.
Skin: No rashes; no changes in skin; no erythema or 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: February 28, 2022.
Neurological: Denies change in bladder or bowel control. No headaches; no tremors; no weakness.
Musculoskeletal: No joint 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.
Objective Findings and Physical Examination
Vital Signs: Blood pressure 125/80 mmHg (sitting), Temperature 97°F (oral), Respiratory Rate 22 breaths per minute, Pulse 76 bpm, Heart Rate 90 bpm, BMI 22.2, Weight 173.5 lbs, Height 63 inches.
Constitutional: The patient is well-developed and appropriately dressed. She walked into the office without signs of distress and without assistance. She appears to be in a good mood, though sneezing occasionally.
HEENT:
Head: Non-tender, atraumatic, and symmetric. No hair loss, lesion, or mass.
Eyes: Appear red. No discharge noted; no edema; no lesions on eyelids.
Ears: No edema, erythema, or exudate in bilateral external ear canals.
Nose: Pale, boggy nasal mucosa; enlarged nasal turbinates; runny with clear mucus.
Throat/Mouth: Mildly erythematous.
Pulmonary: No dyspnea; no difficulty breathing; wheezing noted.
Cardiovascular: No murmur, rub, or gallop; no masses; regular heart rate and rhythm; no heaves or thrills.
Abdomen: Symmetrical, flat, soft, and without distension. Bowel sounds present and normal. No skin abnormalities.
Musculoskeletal: Patient is alert and fully oriented. She can move all extremities without pain. Reflexes are symmetrical with no signs of joint swelling or weakness.
Lab/Diagnostic Test Results (all lab tests performed at the patient's PCP office on March 1, 2022):
WBC: Hct 38.0; Blood glucose 102 mg/dL; Hgb 12,350; Retic 1.3; Diff Na; Troponin 24; ALT 25 IU/L; Alkaline phosphatase 153 IU/L.
EKG: NSR 93; sporadic unifocal VPCs; MB fraction positive.
Assessment and Primary Diagnosis
1. Allergic rhinitis (hay fever), evidenced by runny nose, sneezing, nasal congestion, itchy nose, itchy eyes, itchy throat, and ear fullness (Small, Keith & Kim, 2018). This condition is essentially an allergic reaction to tiny airborne particles and can persist for several weeks or longer. The patient's symptoms represent the classic presentation of this condition and follow a clear seasonal pattern occurring in spring.
2. No other significant health problems or concerns identified.
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