Episodic/Focus SOAP Note

Comprehensive SOAP Template

Introduction

This comprehensive Note is intended to give a clear understanding of the patient health condition

and to aid in the development of a treatment. With this process it is easier to visualize and

organize the information obtained from the provided scenario. By reviewing subjective data,

objective data, Assessment, and developing a Plan order we aim to re-stablish appropriate health

status to the patient. With this process it remarkably easier organizing ideas and create a picture

of what the patient problems are, what need to be addressed now, and what requires long term

planning or referrals.

CASE STUDY #1: Students with the last names that start with (A-M)

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 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 turbinate’s, which

obstruct airway flow, but his lungs are clear. His tonsils are not enlarged but his throat is mildly

erythematous
Patient Initials: R.J. Age: 50 Years old Gender:50 Years old

SUBJECTIVE DATA:

Chief Complaint (CC): The patient is complaining of nasal congestion, sneezing,

rhinorrhea, and postnasal drainage, itchy nose, eyes, palate, and ears for 5 days.

History of Present Illness (HPI): 50-year-old Caucasian male presents in the office with

complains of nasal congestion, rhinorrhea, postnasal drainage, itchy nose, eyes, palate,

and ears for 5 days. Patient states taking Mucinex OTC the past 2 nights to help him

breathe while he sleeps with minimal relief.

each principal symptom:

1. Location: Ear, Nose, Throat

2. Quality: n/a

3. Quantity or severity: Severely itchy nose, throat and ears for 5 days

4. Timing: it worsens at nighttime

5. Factors that have aggravated or relieved the symptom: mild relief after taking over

the counter Mucinex

nose, eyes, palate, and ears

7. Severity: n/a

Medications: Mucinex OTC, hydrochlorothiazide, lisinopril

Allergies: shellfish. Pollen

Past Medical History (PMH): fracture femur at age 21 post Motor and vehicle accident,

Asthma as a child ( has not had any symptoms since adolescence), Hypertension for 5

years.

Past Surgical History (PSH): Right femur closed ORIF 29 years ago, hospitalized for 2

weeks post motor and vehicle accident 29 years ago.

Sexual/Reproductive History: Sexually active, heterosexual monotonous relationship for

10 years. Use condom for protection.

Personal/Social History: He is single, denies used of recreational drugs, does not smoke,

drinks 1-2 glasses of wine on special occasions. He plays golf weekly and runs daily. He
states eating healthy, he avoids consuming dairy and carbohydrates. He recently moved in

with his girlfriend and they got an adorable black cat called Luna.

Immunization History: flu vaccine 1 year ago, All childhood immunization

Significant Family History: Father- Hypertension, DM. Mother- Rhinitis, Arthritis

Patient had no brother or sisters.

Lifestyle: Patient enjoys playing golf, he runs every day. He is well employed as a project

case manager for a shoe company. Completed MBA, He has many friends from his

sorority and long-time college friend he describes as almost brothers. His parents are

retired and live in Florida, he talks to them often and visits them during the holidays.

Review of Systems:

General: No weight loss, fever, chills, weakness or fatigue.

HEENT: Denies headache, facial or neck pain, Eyes: itchy eyes, PERRLA, no hx

of glaucoma, blurry vision, denies double vision. Ears: itchy, denies hearing

difficulty, discharge, tinnitus. Nose: itchy nose, sneezing, clear nasal discharge,

postnasal drip, Denies changes in olfactory ability, epistaxis.

Breasts: differed

Respiratory: No shortness of breath, no cough, dyspnea, hemoptysis.

Cardiovascular/Peripheral Vascular: No chest pain, chest pressure or chest

discomfort. No palpitations or peripheral edema.

Gastrointestinal: No anorexia, nausea, vomiting, diarrhea, no abdominal pain.

Genitourinary: No urinary distress, denies burning or foul odor.

Musculoskeletal: No muscle weakness

Psychiatric: No history of depression or anxiety

Neurological: alert and oriented x3, appropriate speech and behavior, no

headaches, dizziness, syncope, paralysis, ataxia, numbness or tingling in the

extremities. No bowel incontinence

Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.

Hematologic: No anemia, abnormal bleeding, or bruising

Endocrine: No reports of sweating, cold or heat intolerance, no polyuria,

polydipsia.

Allergic/Immunologic: Allergic to shellfish, no hx of asthma, hives or eczema.

Physical Exam:

Vital signs: BP 130/86, HR 80, TEMP 98.7, Resp.20 ,6,1in ,198lbs and 26% BMI healthy.

General: Alert and oriented x 3, clean, well groomed, pleasant. Well controlled

hypertension otherwise healty. Include general state of health, posture, motor activity, and

gait. This may also include dress, grooming, hygiene, odors of body or breath, facial

expression, manner, level of conscience, and affect and reactions to people and things.

HEENT: Head: normocephalic, Eyes: light colored, lashes with evidence of crusting,

smooth, red bulbar and palpebral conjunctiva. PERRLA. Ears: External structures are

symmetrical, non-tender, no erythema, external canal dry, without cerumen, bilateral

tympanic membranes visualized translucent, flat, pearly gray. Nose: Sinuses and septum

Midline, He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal

turbinate’s, which obstruct airway flow. mild tenderness on palpation of frontal, maxillary

sinuses. Throat: no lesion noted in the hard/soft palate, uvula visible , slight erythema,

rises midline no exudate in oropharynx.

Neck: Trachea and thyroid midline without tenderness, tenderness to submandibular.

Pre/post auricular lymph nodes. No swelling, no bruits. No JVD.

Chest/Lungs: lungs are clear, no adventitious sounds heard on auscultation.

Heart/Peripheral Vascular: normal S1, S2 no murmurs, no arrhythmias, RRR. Positive

pedal pulses bilaterally, positive + 2 popliteal pulses bilateral, no edema.

present in all 4 quadrants, no aortic bruit detected on auscultation, no tenderness with

light palpation.

Genital/Rectal: Deferred

Musculoskeletal: no tenderness noted on palpation, muscles symmetric without evidence

of wasting or tenderness with palpation, strength is 5/5 bilateral arms and legs, able to

maintain flexion against resistance. Appropriate gait, no changes in balance.

Neurological: Alert and oriented x 3, behavior and speech are clear, pleasant. Able to

recall recent and remote events clearly. Appropriate gait, no changes in balance.

Skin: Warm to touch, dry, smooth, no lesions, or rashes. Capillary refill less 2 sec.

Diffuse macules across nose, and maxillary surfaces.

ASSESSMENT:

Diagnosis:

Acute Allergic Rhinitis

In my opinion the patient in our scenario has allergic rhinitis. As evidence by the subjective data,

ROS, and Assessment. The Patient complained of nasal congestion, sneezing, rhinorrhea,

and postnasal drainage, itchy nose, eyes, palate, and ears for 5 days. The objective data showed

that his ears and throat had redness and inflammation, as well as tenderness to submandibular.

Pre/post auricular lymph nodes. Allergic Rhinitis is characterized by inflammatory changes of

symptoms. In this case the patient’s mother had history of Rhinitis, and he has hx of asthma as a

child, as well as allergies to pollen. He also recently moved in with his girlfriend and adopted a

cat. A classic case of Allergic rhinitis present with nasal congestion, with clear mucus discharge,

postnasal drip, nasal itch, and frequent sneezing. Mr. R.J. present all this symptom. He also

presents with boggy nasal turbinate which is also an indication of rhinitis.

Differential diagnosis

1. Strep throat:

Is an acute infection of the pharynx caused by beta streptococcus gram positive group, all

ages are affected, but is most common in children. It presents with an acute onset of

pharyngitis, pain on swallowing mildly enlarged submandibular nodes. It is not associated

with Rhinitis, watery eyes, or congestion as seen in the common cold. This diagnosis could

fit this patient because he also has some of the objective finding that classify strep throat, he

was found to have mildly enlarged anterior cervical lymph nodes, erythema to the pharynx

and has not had any fever. He does not have pain when swallowing and has no children at

home and does not work with children which is common of patients diagnosed with strep

throat. Therefore, I don’t believe it is the appropriate diagnosis for the patient at this time.

2. Acute Blepharitis

Acute blepharitis can be caused by bacterial, staphylococcal or viral infection. Is an

inflammation in the base of the eyelash area, eye redness, and sometimes crustiPng.
I chose this diagnosis because on assessment the patient was noted to have redness to both eyes,

complained of itching and was noted to have crusting, as well as red bulbar and palpebral

conjunctiva.

3. Acute Sinusitis

Is a bacterial infection of one or more of the paranasal sinuses. It is characterized by

inflammation, allergies, overproduction of mucus, increase susceptibility to infection. It usually

persists or worsens after 7-10 days. Patients may have tenderness over frontal or maxillary

sinuses. In the case of Mr. R.J. this is a possibility because he only had his symptoms for 5 days

it is too soon to diagnose. Often Allergic rhinitis if untreated causes progression of other diseases

and infections such as sinusitis. Our patient is observing some symptoms that indicate that his

diagnosis might soon change, as evidenced by the tenderness mild tenderness on palpation of

frontal, maxillary sinuses.

4. Non-Allergic Rhinitis

In this case the patient may have many of the symptomatology, he experiences sneezing,

postnasal drainage, rhinorrhea, nasal congestion and itching. All of this are cardinal

symptoms of rhinitis of non -allergic rhinitis what is different is that the patient has no viral

symptoms such as fever, malaise, weakness, headache. Therefore, I believe this diagnosis

while close is not appropriate.

5.Acute bacterial Rhinosinusitis

This diagnosis is characterized by facial pain and pressure, nasal congestion, nasal drainage,

postnasal drip, inflammation of nasal turbinate’s causing difficulty breathing, and mucus
 build up. This type of bacterial infection is most commonly seen in patient that have viral

symptoms and had no improvement by day ten, in most cases getting worse after day five.

For this diagnosis to our fit our patient he would have to be experiencing more symptom such

as chills, fever, yellow or green mucous discharge, facial pain and headaches. Mr. R. has not

experienced any intracranial pressure, or headaches, but he is still within the 10 days it takes

for manifestation and development as of now although not very likely this could still be a

possibility.

PLAN:

Treatment Plan:

Pharmacological: normal saline spray 2 sprays to each nostril 3 times a day. Flonase 50

mc. spray 2 sprays per nostril daily. .Zyrtec 10 mg po daily

Non-Pharmacological: Clean and disinfect areas where allergens could accumulate. Salt

and water gargles. Eat Jell-O, drink cold clear liquids to sooth throat. Avoid pet in bed,

use a HEPA filter.

Health Promotion: Continue exercise practices, maintain a clean airy free diet, avoid

environmental irritants, avoid contact with allergens. Consult allergy specialist.

Disease Prevention: Avoid possible irritants.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to

physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier

Mosby.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M. (2017). Bate’s guide to physical examination and

history taking (12th ed.). Phildelphia, PA: Wolters Kluwer.

Leik, M. T. C. (2014). Family nurse practitioner certification intensive review: Fast facts and

practice questions (2nd ed.). New York, NY: Springer Publishing Company, LLC.

Rosenthal, L. D., & Burchum, J. R. (2018). Lehner’s pharmacotherapeutics for advanced

practice providers. St. Louis, MO: Elsevier.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis

Company.

T., C. L. M. (2014). Family nurse practitioner certification intensive review: fast facts and

practice questions. New York, NY: Springer Publishing Company.