Episodic or Focused SOAP (Nursing) Note on Rhinitis

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Episodic or Focused SOAP (Nursing) Note on Rhinitis

Patient Information: 28-year-old KJ Asian female

S

CC itchy eyes, a runny nose, ears felt full

HPI: 28f-year-olde male suffers from discomfort caused by a runny nose, itchy eyes, and sensation of a blockage in ears. The symptoms started 9 days ago and included production of clear and boggy mucus, photophobia, phonophobia. The character is tickle in her throat, redness and burning around the eyes. The possible timing is every spring and lasts six to eight weeks. There is relieving factor like Claritin, but exacerbating factor is light that bothers eyes. The severity of the pain is rated to be 8 out of 10 since the patient sometimes wants to scratch them out.

Current Medications: Claritin to relieve runny nose, 50 mg twice a day.

Allergies: PCN-rash; food wheat and Barley; environmental- pollen and dust; UTD on immunizations, Covid vaccine #1 5/4/2021 Johnson; Covid vaccine #2 11/4/2021 Johnson

Soc Hx: The office worker with a family comprising of a wife and two daughters. Hobby: swimming once a week. Negative for tobacco, consumes beer occasionally and cannabis.

Fam Hx: Brother has active bronchitis

ROS:

GENERAL: A runny nose, itchy eyes, full ears, sneezing, and tickle in the throat.
HEENT: Eyes: Denies visual loss, blurred vision, but accepts burning of eyes. Ears, Nose, Throat: experienced runny nose, tickle in the throat, sneezing, sometimes she feels chest discomfort.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Negative for dyspnea, orthopnea, PND. Feeling chest pain and chest discomfort.
RESPIRATORY: Positive for intermittent dyspnea on exertion, cough, or hemoptysis
GASTROINTESTINAL: Positive for loose stools with mucous
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, 21/09/2022.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
LYMPHATICS: Nodes are enlarged.
ALLERGIES: Denies history of asthma, but has allergy to pollen and dust.

O

Physical exam: VS: BP 90/82; P 80; R 22; T 97.8; 02 96% Wt 250lbs; Ht 60

General: the patient seems diaphoretic and nervous.

Cardiovascular: CMI lies in the 5th intercostal space, at the midclavicular line. The most excellent place to hear a grade 2/6 systolic decrescendo murmur is at the second right intercostal space, radiating to the neck.

At the pinnacle, a third sound is heard. There is no fourth heart sound or rub heard. There is no cyanosis.

The presence of clubbing is recognized, as is the presence of bilateral 2+ LE edema.

Wheezing is heard in the left lung.

Gastrointestinal: The abdomen is symmetrical and free of distention; bowel

Sound quality and intensity are typical all around; A bruit can be heard in the right para-umbilical region. There are no crowds or Splenomegaly seen. Deep palpation revealed mid-epigastric discomfort.

Pulmonary: Lungs are clear to bilateral auscultation and percussion.

Diagnostic results: Only CXR values were obtained. Findings are not specific, but there increased interstitial markings consistent with the thickening of bronchial walls (Singh et al., 2021). The lungs are clear. No infiltrates.

A

Differential Diagnoses

Allergic Rhinitis. The most disturbing symptoms match: sneezing, nasal congestion, nasal itching and rhinorrhoea (nasal discharge) caused by immunoglobulin E (IgE)-and involve mucosal inflammation (Bousquet, 2020). Since the symptoms occur every year at the expected time, allergic rhinitis is the most suitable diagnosis as certain allergens cause it.
Bronchitis. Has the same symptoms: runny nose, dull pain in the chest under the, shortness of breath, sputum production (Rahila et al., 2017).
Chronic sinusitis and hyper-adenoidal tissue. Experiences similar symptoms cough, mild headache, and tearing with runny nose, and pain around the eyes (Manning et al., 2018).
Throat erythema as the patient has fever, swollen or tender anterior cervical lymph node, but cough contradicts erythema (Abika et a., 2019).
Covid-19. Shortness of breath, the loss of smell are common, but sneezing, itchy eyes, and runny nose occur rarely (Salehi-Abari & Khazaeli, 2020).

Primary Diagnosis/Presumptive Diagnosis: Allergic Rhinitis with Acute bronchitis

References

Abiko, T., Sato, T., & Mitsui, T. (2018). Evaluating erythema of the throat using a thin USB camera in children with group A beta-hemolytic streptococcal pharyngitis. Bulletin of the Yamagata University. Medical science: Yamagata medical journal, 36(2), 121-127. Web.

Bousquet, J., Anto, J. M., Bachert, C., Baiardini, I., Bosnic-Anticevich, S., Walter Canonica, G., & Toppila-Salmi, S. (2020). Allergic rhinitis. Nature Reviews Disease Primers, 6(1), 1-17. Web.

Manning, N., Wu, P., Preis, J., Ojeda-Martinez, H., & Chan, M. (2018). Chronic sinusitis-associated antrolith. IDCases, 14. Web.

Rahila, A., Muhammad, A., Akash, T., Sakina M. (2017)/ A review on antiviral activity of the Himalayan medicinal plants traditionally used to treat bronchitis and related symptoms. Journal of Pharmacy and Pharmacology, 69(2), 109122.

Salehi-Abari, I., & Khazaeli, S. (2020). COVID-19 versus allergic rhinitis. Advances in Infectious Diseases, 10(03), 168.

Singh, A., Avula, A., & Zahn, E. (2021). Acute bronchitis. In StatPearls. StatPearls Publishing. Web.

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