SOAP Note For Skin Conditions

Lab Assignment

Patient Information: R.S, 50-year-old male

Subjective

CC: Nasal congestion as well as itching for the last 5 days

HPI: R.S is a 50-year-old male that came to the unit with complaints of nasal congestion, rhinorrhea, sneezing, itchy nose, postnasal discharge, and itching ears and nose for the last 5 days. The patient reported using Mucinex medication to help ease breathing but it has been associated with minimal effectiveness. The patient denied any history of pain or headache.

Medications: The patient currently uses Mucinex over-the-counter medication 1 tab orally on a daily basis.

Allergies: The patient denied any history of drug or food allergy. The patient reported history of seasonal allergies.

PMHx: The patient denied history of hospitalization, surgery, and blood transfusion. The immunization history of the client is up to date.

Social Hx: The patient is married with two children. The patient stopped smoking in 2012. He drinks alcohol on occasional basis. His highest level of education is university. He has a degree in business administration and works at a local supermarket as a manager. He reported to engage in active physical activity. He reported that the symptoms of the disease had affected his sleeping patterns significantly.

Family Hx: The parents of the patient are both alive. His father was diagnosed with diabetes in 2016 and has been on treatment. His mother was diagnosed with hypertension in 2020 and is on treatment. The patient is the second born in a family of three. His siblings are all alive and healthy.

ROS

General: The patient appeared well groomed for the occasion. He was oriented to time, place, and self. He denied fevers, fatigue, or chills. The patient reported being tired due to lack of enough sleep secondary to the symptoms of the health problem.

HEENT: The patient denied headaches. The patient reported that his eyes are itchy and red. There were no changes in the vision. The tympanic membranes are intact, with absence of ear drainage of changes in hearing. The patient reported nasal congestion, itchy, with pale and boggy nasal mucosa. There was clear nasal drainage with slightly enlarged nasal turbinates. There was absence of tonsillitis. The throat was mildly erythematous.

Neck: The trachea was midline without any deviation or lymphadenopathy.

Skin: The patient denied skin rash, changes in skin color, and itching.

Cardiovascular: The patient denied chest pain, palpitations, discomfort, or edema.

Respiratory: The patient denied shortness of breath, cough or difficulty in breathing

Musculoskeletal: The patient denied joint or muscle pain.

Lymphatic: The client denied lymphadenopathy

Allergies: The client denied any known food or drug allergy. He reported seasonal allergies.

Objective

HEENT: The patient reports that his eyes are itchy. The eyes appear red. The tympanic membranes are intact with the absence of any drainage. The nasals are congested, with boggy, pale mucosa and inflamed nasal turbinates. There is the evidence of drainage of thin, clear secretion. There is mild erythema on the throat with absence of tonsillitis and bleeding.

Diagnostic Results

The skin test revealed a positive reaction to pollen. The results showed that the patient has allergic rhinitis. Allergic rhinitis is a condition of the upper respiratory system that arises from an individual exposure to an allergen. Patients experience symptoms that include sneezing, rhinorrhea, itchy nose and eyes, nasal congestion, and sore throat among others. Diagnostic investigations are not recommended in allergic rhinitis since they do not have any cost benefits. Healthcare providers can utilize history taking and physical examination to diagnose patients with the condition. It is however important to perform tests such as skin tests to determine whether a patient has allergic rhinitis in people without history of allergic reactions.

Differential Diagnosis

Allergic Rhinitis: The first differential diagnosis for the patient is allergic rhinitis. As noted initially, allergic rhinitis is a respiratory condition that develops following an individual exposure to an allergen. The symptoms associated with allergic rhinitis include sneezing, nasal congestion, rhinorrhea, and itchy eyes. The symptoms developed due to IgE mediated reactions against the allergens (Okubo et al., 2020). Allergic rhinitis is the primary diagnosis for the patient due to the positive skin test.

Non-allergic rhinitis: Non-allergic rhinitis is the other possible condition affecting the client. Patients present with symptoms such as nasal congestion, rhinorrhea, sneezing, and itchy eyes among others. However, patients do not have history of allergic reactions to allergens (Zheng Ming et al., n.d.). This is the least diagnosis for the client in the case study because he has history of seasonal allergy.

Sinusitis: sinusitis refers to a condition where the paranasal sinuses are inflamed. Sinusitis is attributed to causes such as fungal, viral or bacterial infections and allergic reactions. Patients with sinusitis experience symptoms such as nasal congestion, headache, rhinorrhea, fever, and facial pain (Little et al., 2018). Sinusitis is however, the least possible condition due to the absence of signs and symptoms associated with infections.

Flu/Common cold: Common cold is the other potential diagnosis. Common cold is an acute viral infection affecting the upper respiratory system. It may involve sinuses, larynx or the pharynx. Patients experience symptoms such nasal drainage, malaise, fever, and headache among others. It is however the least likely due to the absence of signs and symptoms of infection (Sadeghirad et al., 2017).

Sore throat: Sore throat is the other potential diagnosis for the patient. Patients experience pain in the pharynx on swallowing. Sore throat is largely attributed to viral infections. The patient however is least suffering from sore throat because of the absence of signs and symptoms of infection (Mahalingam et al., 2020).

References

Little, R. E., Long, C. M., Loehrl, T. A., & Poetker, D. M. (2018). Odontogenic sinusitis: A review of the current literature. Laryngoscope Investigative Otolaryngology, 3(2), 110–114. https://doi.org/10.1002/lio2.147

Mahalingam, N. V., Abilasha, R., & Kavitha, S. (2020). Awareness of symptomatic differences COVID-19, sars, swine flu, common cold among dental students. International Journal of Research in Pharmaceutical Sciences, 11(Special Issue 1). https://doi.org/10.26452/ijrps.v11iSPL1.3431

Okubo, K., Kurono, Y., Ichimura, K., Enomoto, T., Okamoto, Y., Kawauchi, H., Suzaki, H., Fujieda, S., Masuyama, K., & Allergology, T. J. S. of. (2020). Japanese guidelines for allergic rhinitis 2020. Allergology International, 69(3), 331–345. https://doi.org/10.1016/j.alit.2020.04.001

Sadeghirad, B., Siemieniuk, R. A. C., Brignardello-Petersen, R., Papola, D., Lytvyn, L., Vandvik, P. O., Merglen, A., Guyatt, G. H., & Agoritsas, T. (2017). Corticosteroids for treatment of sore throat: Systematic review and meta-analysis of randomised trials. BMJ, 358, j3887. https://doi.org/10.1136/bmj.j3887

Zheng Ming, Wang Xiangdong, Ge Siqi, Gu Ying, Ding Xiu, Zhang Yuhuan, Ye Jingying, & Zhang Luo. (n.d.). Allergic and Non-Allergic Rhinitis Are Common in Obstructive Sleep Apnea but Not Associated With Disease Severity. Journal of Clinical Sleep Medicine, 13(08), 959–966. https://doi.org/10.5664/jcsm.6694