Practicum SOAP Note paper
Chief complaint: a persistent runny nose for three weeks
History of presenting complaint: W.R is a 76-years old American female complaining of a persistent runny nose for three weeks associated with nasal drainage, clearing of the throat, and occasional nasal congestion on waking up. The patient states that the trigger of these symptoms is spring season pollination. She also reports having an itching nose, eyes, and palate, tearing, red eyes, drowsiness, fatigue, and eye swelling. She denies chest pain, coughing, wheezing, sputum production, fast breathing, and shortness of breath. Practicum SOAP Note paper
Past medical history: the patient has had osteoarthritis, diabetes mellitus, and hypertension. She has a positive history of hospitalization in her youthful years due to diabetes keto-acidosis. She denies a history of cancer, mental illness, and asthma.
Immunization: her immunization schedule is up to date. Her last H. influenza and the pneumococcal vaccine was three months ago.
Past surgical history: she has had two cesarian sections each five years apart.
Allergies: the patient develops heaves and running nose when exposed to pollen, dust, or fur and relieves by taking an antihistamine. She denies food and drug allergy.
Current medication: Lantus insulin 28Iu SC in the morning and 14Iuin in the evening for glycemic control. Aspirin 81mg per oral once daily for pain. vitamin D and calcium supplementation for osteoarthritis. Hydroxyzine 50mg PO PRN for allergic reaction.
Family history: the patient is the thirdborn in a family of five. Her father passed on at the age of 80years due to COPD and her mother passed on at the age of 67years years due to a heart attack. Her elder sister passed on at the age of 70years due to status asthmaticus. Her elder and younger brother are living with hypertension and asthma. She denies a family history of cancers and mental illness.
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Social history: the patient is widowed. She has two children who live in another state. She is a retired lecturer. She recently moved into an independent living center because of loneliness and to get help for activities of daily living. She enjoys reading and singing in the church choir. She denies the use of alcohol and smoking. She does not engage in physical exercise because of joint pain. she takes food with low sodium to control her blood pressure.
Reproductive history: the patient is in her menopausal period. Her last menstrual flow was 25years ago. Her menarche was at the age of 15 years. She has had a regular 28days cycle with three days of moderate flow. She denies a history of dysmenorrhea and pre-menstrual syndrome. She denies the use of contraception. She has two children born via the cesarian section due to breech presentation. She has had one sexual partner in her lifetime. She denies sexually transmitted infections. Her last pap smear was negative. Practicum SOAP Note paper
Review Of Systems
General: The patient denies fever, chills, rigors, weight loss, and weight gain
Cardiovascular system: the patient denies syncope, dizziness, paroxysmal nocturnal dyspnea, palpitations, tachycardia, orthopnea, and edema.
Gastrointestinal system: she denies bloating, abdominal pain, diarrhea, constipation, nausea, heartburn, loss of appetite, reflux, vomiting,
Genitourinary system: she denies dysuria, polyuria, hematuria, urine incontinence, urgency, vaginal bleeding, vaginal discharge, and lower abdominal pain.
Musculoskeletal: she complains of joint pain and stiffness. However, she denies muscle spasms and numbness.
Neurological system: the patient denies facial droop, numbness, of extremities, reduced reflexes, muscle weakness, loss of consciousness, and convulsions.
Psychiatric: the patient states that she feels lonely after her husband passed on. She denies anxiety, depression, impaired concentration, and psychosis.
General: the patient is calm and oriented. She has no cyanosis and edema.
Vitals: Blood pressure is 130/84 mmHg, temperature 98.6, pulse 78, respiratory rate 20. WT: 70kgs, HT 1.51m, and BMI 30kg/m2.
HEENT: the nose is erythematous with swollen nasal turbines and has thin watery secretions. There is no septum deviation or perforation, nasal polyps, and nasal tumors. The eyes are red and watery. The ears are erythematous with no swelling and secretions. The mouth cavity is moist and pink. There is no pharyngeal swelling.
Skin: the facial skin is pink and erythematous. There is no rash or bruises.
Respiratory examination: the chest has symmetrical expansion when breathing. There is no mass, scars, erythematous skin, and swelling. There is a resonant percussion note. There are transmitted sounds in the lung zones. However, there is no rhonchi, stridor, crackles, or wheezing.
Cardiovascular system: the heart is normative at the 5th ICS. Normal sounds S1 and S2 are present without murmurs and pericardial rub. The peripheral arterial pulse is present at a normal volume, regular rate, and rhythm. There are no palpable bruits.
Abdominal examination: the abdomen is round, has no scars, obvious mass, and striae. The bowel sounds are present in the four quadrants. There is a tympanic percussion note with no shifting dullness. The abdomen is soft with no areas of tenderness.
Diagnostic tests and findings
Total eosinophil count and total serum IgE are specific for allergic rhinitis. An allergy skin test helps determine IgE-mediated sensitivity (Wang, et al, 2018). Face and head radiographs evaluate for possible structural abnormalities like adenoid hypertrophy and sinusitis. Face CT scan helps evaluate acute and chronic sinusitis. Complete blood count with differentials to rule out infections. Throat swab for culture to rule out bacteria rhinosinusitis.
- Allergic rhinitis J30.9: Allergic rhinitis is the inflammation of the mucus membrane of the nose, middle ear, sinuses, and the eyes. The allergic reaction is an IgE-mediated hypersensitivity after exposure to allergens (Zhang, Y., & Zhang, L. 2019). The mediators cause the release of mast cells and histamine. The interaction of these two causes rhinorrhea, sneezing, itchiness, redness, tearing, swelling, post nasal drip, increased secretions, and plasma exudation. Vasodilation of the mucus membrane causes nasal congestion and increased pressure. The persistence of these mediators leads to the production of inflammatory cells, increasing nasal congestion and mucus secretion. The inflammatory response causes fatigue, drowsiness, and malaise. The patient was exposed to pollen at the beginning of spring three weeks ago. Pollen triggered the IgE mediators and inflammatory cells hence her symptoms of nasal drainage, clearing of the throat, and occasional nasal congestion on waking up.
- Acute sinusitis J01.90: Acute sinusitis is the inflammation of paranasal sinuses associated with concurrent rhinitis. It is common in females above 64years old. The concurrent rhinosinusitis may be caused by bacterial, fungal, and viral infections. The presenting symptoms are a headache in the temporal region, facial fullness, hyposmia, blocked nose, redness of the nose and the eyes, persistent coughing and laryngeal irritation, nasal congestion, fever, and ear pressure (DeMuri, et al, 2019). The patient presents with similar symptoms nasal drainage, clearing of the throat, and occasional nasal congestion on waking up. However, it is not the actual diagnosis because the patient denies coughing, fever, headache, ear pain, and facial fullness. A nasal cytology test is appropriate to rule out allergic rhinitis and nasal polyps.
- Upper respiratory tract infection J06.9: An upper respiratory tract infection is a self-limiting infection of the nasopharynx. The pathogens causing upper respiratory tract infection are bacteria, viruses, and fungi. The most common bacteria agent is group A streptococcus. Viral agents are rhinoviruses, coronaviruses, adenoviruses, and coxsackieviruses. Causes of upper respiratory tract infections are obstruction from allergic rhinitis, smoking, contact with people with upper respiratory tract infections, trauma to the airway, and immunosuppression. Commonly, I school-going children younger than 5 years and elderly patients above 60. The clinical signs and symptoms are nasal mucosal erythema, nasal discharge, foul breath, fever, cervical lymphadenopathy, sore throat, muffled dysphonia, dry cough, tonsillar hypertrophy, fatigue, and sniffing posture (Vorilhon, et al, 2019). This is not the patient’s diagnosis because she denies fever, coughing, and headache. She has no history of contact with a patient with an upper respiratory tract infection.
- Mometasone nasal spray twice daily to relieve inflammation and nasal congestion
- Montelukast 10mg PO once daily to prevent the action of mast cells and eosinophils.
- Sublingual immunotherapy to prevent recurrent allergic rhinitis
Observe environmental control measures like reducing outdoor exposure and keeping the doors and windows closed during the season (Seedat, R. Y. 2019). Thorough vacuum cleaning of rugs and carpets to get rid of pollen and dust.
DeMuri, G. P., Eickhoff, J. C., Gern, J. C., & Wald, E. R. (2019). Clinical and virological characteristics of acute sinusitis in children. Clinical Infectious Diseases, 69(10), 1764-1770. https://doi.org/10.1093/cid/ciz023
Seedat, R. Y. (2019). Environmental control of outdoor allergens. Current Allergy & Clinical Immunology, 32(1), 12-14. https://hdl.handle.net/10520/EJC-15b23dc43b
Vorilhon, P., Arpajou, B., Vaillant Roussel, H. et al. Efficacy of vitamin C for the prevention and treatment of upper respiratory tract infection. A meta-analysis in children. Eur J Clin Pharmacol 75, 303–311 (2019). https://doi.org/10.1007/s00228-018-2601-7
Wang, X., Du, K., She, W., Ouyang, Y., Sima, Y., Liu, C., & Zhang, L. (2018). Recent advances in the diagnosis of allergic rhinitis. Expert review of clinical immunology, 14(11), 957-964. https://doi.org/10.1080/1744666X.2018.1530113
Zhang, Y., & Zhang, L. (2019). Increasing prevalence of allergic rhinitis in China. Allergy, asthma & immunology research, 11(2), 156-169. https://doi.org/10.4168/aair.2019.11.2.156
History of Present Illness (HPI): MB is a 34-year-old African American female, who presents for her initial visit seeking primary care services. She reports having issues with feeling fatigued and tired through the day. Patient reports she has a PMH of lupus and she is currently being seen by a specialist for lupus. She is taking medications for treatment of lupus. She reports having insomnia for many years, into her childhood. She reports her fatigue is worsening her sleep, because she is so used to being fatigued, her body tends to remain in that state and is not able to fully rest when she wants to at night. She has taken melatonin but denies taking it consistently to see if it is effective for her. She reports her sleep is at least 5/6 hours of sleep and is not restful upon awakening in the morning. She states that her appetite is stable and sporadic, often ‘grazing’ or snacking on meals through the day. She denies any history of nightmares or night terrors. She denies feelings of depression at this time. Denies SI/HI or hallucinations.
Past Medical History (PMH):
Childhood illnesses: Insomnia
Adult illnesses: Lupus, Anxiety disorder, insomnia
Immunization: Up to date.
Surgeries: No significant surgical history
Allergies: No known allergies
Adderall 10 mg tablet: one tablet (10 mg) by oral route once daily before breakfast for Lupus
Valium 5 mg tablet: one tablet PO daily PRN for Anxiety
B Complex-Vitamin B12 tablet: one tablet by mouth daily for supplement
Classic Prenatal 28 mg iron-800 mcg tablet: one tablet daily for supplement
Melatonin 3mg: take 2 tablets PRN for insomnia
No significant family history
Married. Denies current use of tobacco and illicit drugs. Drinks alcohol socially
- General: Positive for fatigue and general weakness. Negative for night sweats, fever, chills
- Head: Negative for dizziness, lightheadedness
- Neck: Negative for neck pain and stiffness
- Eyes: Negative for pain and visual disturbances
- Ears: Negative for ear discharge, tinnitus
- Nose: Negative for sinus pain.
- Mouth & Throat: Negative for sore throat, bleeding gums or wounds in mouth.
- Cardiovascular: Negative for chest pain, palpitations, syncope, chest tightness
- Respiratory: Negative for cough, shortness of breath, wheezing
- Gastrointestinal: Negative for abdominal pain, nausea, and vomiting. Reports gas and bloating after alcoholic drinks
- Musculoskeletal: Positive for muscle weakness. Negative for swelling and stiffness.
- Neurological: Negative for paresthesia, tremors, seizures, vertigo
- Psychiatric: Positive for anxiety, negative for depression
- Vital signs: Signs: Temp: 98F, HR: 76, BP: 124/76, RR: 20, Oxygen sat. 100%
Height: 68 inches, Weight: 120lbs, BMI: 19.37
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- General Appearance: Well groomed, appears stated age
- HEENT: Head: Normocephalic. Symmetric. Eyes: EOMI. Conjunctiva pink. Sclera white. Ears: Hearing grossly intact. Normal pinnae with no rashes. Canals clear. Tympanic membranes are pearly gray with visible landmarks, no erythema, intact with light reflex visualized bilaterally. Nose: Nasal mucosa pink and moist. Frontal and maxillary sinus tenderness. Throat: Oral mucosa pink and moist. Tongue midline. Practicum SOAP Note paper
- Neck: Supple with full ROM. Trachea midline. Thyroid palpable WNL
- Lymph Nodes: No nodules or cervical lymphadenopathy
- Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, clicks or gallops
- Respiratory: Normal symmetrical chest expansion without use of accessory muscle. Negative tactile fremitus, no chest wall tenderness, CTAB, no cough, no rales or crackles audible, no area of diminished breath sounds
- Gastrointestinal: Positive bowel sounds in all four quadrants. Abdomen soft, benign, non- tender, and non-distended. No palpable masses and no CVA tenderness
- Skin: Skin uniformly warm and dry. Discoloration to left arm
- Musculoskeletal: Full ROM
- Neurologic: Cranial nerves intact. Alert and oriented x 4
- Psychiatric: Appropriate mood and affect. Maintains eye contact throughout interview and examination.
Diagnostic testing/ Findings
Labs: CBC with Absolute Neutrophil count, CMP, Lipid profile, PSA, TSH, Vitamin D, Hemoglobin A1c ordered.
- Primary diagnosis
Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease. It tends to affect many organ systems. Spontaneous remissions and exacerbations characterize the clinical picture. SLE can be mild or aggressive and even life-threatening in presentation (Williams, Chang, Ahalt, Chen, Conant et al, 2014). Constitutional symptoms such as fatigue, fever, and weight loss are present in most patients with systemic lupus erythematosus (SLE) at some point during the course of the disease. Fatigue is the most common complaint, occurring in 80 to 100 percent of patients, and can sometimes be disabling. Its presence is not clearly correlated with other measures of disease activity and is more frequently associated with depression, sleep disturbances, and concomitant fibromyalgia (Wallace & Gladman, 2021). Practicum SOAP Note paper
- Differential diagnosis:
- Anemia of chronic disease/anemia of inflammation (ACD/AI): ACD/AI is considered the second most common cause of anemia worldwide, after iron deficiency anemia. However, detailed statistics on its prevalence are not available. Often the anemia in individuals with inflammatory diseases is complex and multifactorial, and it may be challenging to separate out the component due to ACD/AI. Examples of the prevalence of ACD/AI in various inflammatory states include systemic inflammatory disorders. Anemia is observed in 33 to 60 percent of patients with rheumatoid arthritis and in a variable percentage in patients with systemic lupus erythematosus, inflammatory bowel disease, vasculitis, or systemic sclerosi The typical patient with ACD/AI has a known underlying chronic condition with an inflammatory component. The patient may be more symptomatic from their underlying condition than from their anemia, although fatigue may be common to both and may be challenging to attribute (Camaschella, & Weiss, 2021).
- Generalized Anxiety disorder: Generalized anxiety disorder (GAD) is characterized by excessive and persistent worrying that is hard to control, causes significant distress or impairment, and occurs on more days than not for at least six months. Other features include psychological symptoms of anxiety, such as apprehensiveness and irritability, and physical (or somatic) symptoms of anxiety, such as increased fatigue and muscular tension. Although excessive and persistent worrying is widely regarded as the pathognomonic feature of GAD, most patients present with other symptoms relating to hyperarousal, autonomic hyperactivity and muscle tension. Many patients complain of poor sleep, fatigue and difficulty relaxing (Baldwin, 2021).
- Insomnia: Insomnia is the one of the most common medical complaints. It frequently coexists with medical, psychiatric, sleep, or neurological disorders. It may also be associated with acute stress, medication or substance, poor sleep habits, or changes in the sleep environment. Insomnia symptoms that occur at least three times per week and persist for at least three months are considered chronic insomnia. Severe fatigue is commonly reported by patients with chronic insomnia (Bonnet & Arand,2021). Practicum SOAP Note paper
- Advised to take medications as prescribed.
- Advised to monitor blood pressure and HR at home, keep a log.
- Advised to monitor diet and eat smaller meals, especially before medication is taken, if weight loss is noted.
- Sleep Hygiene: Discussed utilizing sleep with no light, no eating 2 hours prior to sleep and no use of stimulation: television, electronics, or devices to aid in sleep.
- Notify Provider of any new medications, to make sure there is no interaction between the medications taken.
- Follow up scheduled for one month, or sooner if needed.
Baldwin, D (2021) Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. Retrieved from https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis?search=anxiety%20disorders&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H448541448
Bonnet, M.H & Arand, D. L (2021). Evaluation and diagnosis of insomnia in adults. Retrieved from https://www.uptodate.com/contents/evaluation-and-diagnosis-of-insomnia-in-adults?search=insomnia&topicRef=97867&source=see_link
Camaschella, C & Weiss, G (2021). Anemia of chronic disease/anemia of inflammation. Retrieved from https://www.uptodate.com/contents/anemia-of-chronic-disease-anemia-of-inflammation?search=anemia%20symptoms&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5#H685556
Wallace, D. J & Gladman, D.D (2021). Clinical manifestations and diagnosis of systemic lupus erythematosus in adults. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-systemic-lupus-erythematosus-in-adults?search=lupus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Williams, B. A., Chang, A., Ahalt, C., Chen, H., Conant, R., Landefeld, C. S., Ritchie, C., & Yukawa, M. (2014). Current diagnosis and treatment: Geriatric (2nd ed.). McGraw Hill Education.
A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms. Chief complaint: Persistent “runny nose” for 3-week duration, associated clearing of throat, and nasal congestion on awakening in the morning. Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20. WT:___ BMI:____ What further ROS questions will you want to ask her? List at least three. What physical exam (PE) will you perform on this patient? List at least three. What are the differential diagnoses that you are considering? Describe at least three (one of them should be the primary dx). What laboratory tests will help you rule out some of the differential diagnoses? You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR). Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient? List at least two treatment options: medications with dose, side effects and/or cautions in the older adult. Write your order in the SOAP note as you would for an actual patient. What education will you provide for this patient and family? When will you have the patient follow up? Be specific. Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note.
Practicum SOAP Note paper