Soap note UTI

Miami Regional University

Date of Encounter: 06/18/2020

Student Name: LWC

Preceptor: Silvio Planas APRN

Clinical Site: Gynecology and More INC.

Clinical Instructor: Kirenia Santiuste

Soap Note # 6

Main Diagnosis: Allergic Rhinitis

PATIENT INFORMATION

· Name: TJ

· Age: 28

· Gender at Birth: Female

· Gender Identity: Female

· Source: Patient

· Allergies: allergies to dust, cats and Penicillin

· Current Medications: Albuterol 90mcg, 1-2 puff qid inhaler PRN when symptoms occur.

· PMH: Asthma

· Immunizations: Up to Date, Refused Influenza vaccination this year due to COVID-19 National Pandemic

· Preventive Care: Avoid allergens, Good house hygiene, Regular exercising, annual checkups.

· Surgical History: Appendicitis.

· Family History: 1st relatives Asthma, Mother and grandparents High blood pressure, Father died on car accident DM.

· Social History: Alcohol drinker 2 cups or rum weekly. Preferred hobby Netflix and sport tv programs.

· Sexual Orientation: Female Preference

· Nutrition History: Low Sodium Diet

Subjective Data:

· Chief Complaint: “I have sore throat and itchy, itchy eyes and runny nose”

· Symptom analysis/HPI: Patient has been with those symptoms for a week, the runny nose and eye itchy are the same but the sore throat got worse lately, the discharge is clear. There is tenderness around the nose. The Symptoms improve drinking water and some drops throat lozenges. Denies fever, no nasal blockage, no chills.

Review of Systems (ROS)

· General: Fatigued, Generalized Weakness.

· HEENT: Runny nose, eyes itchy, sore throat, difficult swallowing, blurred vision when reading, no double vision., denies block nose and no bleeding.

· Neck: Denies neck pain, able to rotate his neck laterally and in and upward position

· Lungs : No cough, shortness of breath, PND, or orthopnea

· Cardiovascular: No pressure, squeezing, tightness, heaviness or aching about the chest, neck, axilla or epigastrium

· Breast: Denies any pain or lumps

· GI: Denies Abdominal Pain

· Female genital : Denies dysuria, frequency and urgency when urinating

· GU : Denies dysuria, no frequency and urgency when urinating

· Neuro: No burning or tingling, sensation present in all quadrants

· Musculoskeletal: No joint pain no restriction motions.

· Activity & Exercise : no habits of exercise.

· Psychosocial: anxious about the disease.

· Derm: denies any rash, bums or recent lesions.

· Sleep/Rest : more than 6 hours a day but with difficult to breath.

Objective Data/Physical Exam

· BP 141/82 TPR 99.1 HT 170 cm WT. BMI 30.1 O2: 99%

· General: Well-groomed, appropriate posture and gait, normal affect, obesity

· HEENT : Tenderness frontal and right maxillary sinus, Weber and Rinne test intact, cranial nerves intact, no hearing loss, vision left eye 20/20 right eye 20/40. whitish discharge noted from the nose. Edema and erythema of nasal mucosa, uvula and Tonsils, redness noted. Halitosis presents.

· Neck : thyroid gland intact no nodules no lymphadenopathy noted

· Pulmonary: lungs clear to auscultation, no adventitious sound throughout the lungs

· Cardiovascular: no abnormal heart sounds normal physiologic S1/S2 present, normal PMI

· Breast: no bumps or lesions

· Abdomen: no abdominal distention, no pain on percussion or palpation, active bowel sounds any signs of liver or spleen enlargement

· Rectal: Refuse assessment

· Male genital : Denies discharge, dysuria, pyuria, pain that radiates to the groin

· Neuro: Cranial nerves intact, no cerebellar dysfunctions, alert x4

· Derm : Acanthosis nigrins around the neck, papules, comedones on the face

· Psych : anxious about disease process

ASSESSMENT

Main Diagnosis:

· Allergic Rhinitis

Differential diagnosis:

· Infectious Rhinitis

· Rhinitis Medicamentosa

· Influenza

· Seasonal allergic.

· Asthma

PLAN:

Labs and Diagnostic Test to be ordered:

· CBC with Differential (pending results)

· Rapid Strep Test done in office (positive in office)

· Influenza Swab (negative in office)

· Covid -19 Swab (pending results)

Education

· Avoid exposure to known allergens

· Frequent hand washing

· Monitoring signs of complication such as fever, change of discharge color, change of senses of smell and taste, nose bleeding.

· Take medications as prescribed.

Non-Pharmacologic treatment:

· Drink plenty of Fluids

Pharmacological treatment:

· Loratadine 10 mg po daily

· Saline nasal drop qid

· Ibuprofen 600mg qid PRN for pain

Follow-ups/Referrals

· Follow up in 2 week. Office

· will call you when lab work is available.

· No referrals needed at this time.

References

Barbara Bates a Guide to Physical Examination

Buttaro, T. et al. (2017). Primary care: a collaborative practice. St. Louis, MO: Elsevier.

Gupta, N., Singh, R., & Saxena, R. K. (2019).

Porter, R. S. (2018). The Merck manual: of diagnosis and therapy. Rahway: Merck Sharp & Dohme Corp. 246 (2080-2080)

Webmd.com