SOAPNOTE
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.
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.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:
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.
P.
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.
Patient Information:
Initials: C.S.
Age: 28
Sex: Female
Race: Not specified
CC: Runny nose, itchy eyes, and full ears for approximately 9 days. States this occurs every spring and lasts 6-8 weeks.
HPI: 28-year-old female presents with a 9-day history of runny nose, itchy eyes, and fullness in the ears. She reports the runny nose causes clear mucus discharge. She experiences sneezing episodes throughout the day. Her eyes itch severely, making it difficult to avoid scratching. She also notes an occasional tickle in her throat. Her ears feel full and pop at times. Last year, Claritin provided relief of her symptoms.
ROS:
General: No weight loss, fever, chills, or fatigue.
HEENT: Eyes: Itching. Ears: Fullness and popping. Nose: Runny with clear discharge. Throat: Occasional tickle.
Respiratory: No cough, sputum, or shortness of breath.
Skin: No rash or itching other than eyes.
PMHx: No major illnesses. Up-to-date on immunizations.
Meds: Claritin as needed last spring, providing relief.
Allergies: No known drug or environmental allergies.
SocHx: Works as an accountant. Enjoys gardening and hiking. Lives with partner. No tobacco, alcohol, or drug use.
FamHx: No notable illnesses.
Physical Exam:
Constitutional: Well-nourished and well-developed. In no acute distress.
HEENT: Bilateral conjunctival injection. Clear nasal discharge. No throat erythema. Normal ear exam.
Respiratory/Cardio: Clear breath sounds. Regular rate and rhythm.
O: Based on the history and physical exam findings, the leading differential diagnoses are allergic rhinitis and non-allergic rhinitis.
A: 1. Allergic rhinitis: Seasonal symptoms, itchy eyes, relief with antihistamine last year support.
Non-allergic rhinitis: Absence of identifiable allergen triggers rhinitis without allergy.
P: Recommend trial of loratadine 10mg daily for 2 weeks to treat presumed allergic rhinitis. Advise use of saline rinses and avoidance of known triggers. Follow up if symptoms persist after treatment.
References:
Wallace, D., Dykewicz, M., Bernstein, D., Blessing-Moore, J., Cox, L., Khan, D., … & Schatz, M. (2008). The diagnosis and management of rhinitis: an updated practice parameter. Journal of Allergy and Clinical Immunology, 122(2), S1-S84.
Bousquet, J., Khaltaev, N., Cruz, A. A., Denburg, J., Fokkens, W. J., Togias, A., … & Canonica, G. W. (2008). Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2) LEN and AllerGen). Allergy, 63(s86), 8-160.
Wallace, D. V., Dykewicz, M. S., Oppenheimer, J., Portnoy, J. M., Lang, D. M., Kemp, S. F., … & Schatz, M. (2012). Pharmacologic treatment of seasonal allergic rhinitis: synopsis of guidance from the 2017 ARIA update. World Allergy Organization Journal, 5(12), 1-16.
