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SOAP NOTE

Subjective

Patient Demographics: The patient is a 22 year old female, was brought in to the clinic by her boyfriend. The patient is non Hispanic, Caucasian, is Jewish and has Medicaid insurance.

Chief complaint: “I have been having a cough for past 3 days”

History of presenting illness: The patient is a 22-year-old female reporting persistent cough for the previous three days. The cough is worse at night and that a runny nose can occasionally accompany it. There have been no reports of fever, chills or nausea. Patient denies having any recent interactions with sick people or traveling out of the country.

Past Medical History: Denies any past medical history.

PSH: Denied any past surgical history.

Allergies: No known allergies

Untoward Medication Reactions: Patient denied untoward medication reaction

Immunization status: Up to date.

Family Medical History:

· Father (Alive): Diagnosed with Hyperlipidemia 4 years ago. Age 48

· Mother: Reports allergies to pollen, diagnosed 2 years ago. Age 45

· Siblings: One brother (age 12). No significant medical history.

Social History:

Education: In College studying Nursing

Occupational history: N/A

Current living situation/partner/marital status: Patient is living with both parents and younger brother. No reports of any domestic, abuse or safety issues.

Leisure Patterns: Patient is active, likes to go to the library on weekends to study, and reports she is on a soccer team which she plays in spring and summer seasons.

Safety status: No exposure to firearms or any safety concern. Wears helmet when riding her bike.

Spirituality: Jewish

Nutrition: Has a well balanced diet

Sleep Patterns: Patient follows a regular sleep schedule

Current Medications/OTCs/Supplements: None

Review of Systems:

General: Patient appears well nourished, reports cough and rhinitis.

HEENT:

Head: Denies headaches. Denied tinnitus, blurred vision, difficulty focusing, visual changes, and dry eyes.

Eyes: Denies visual loss. Does not wear corrective lenses.

Ears: Denies difficult hearing, pain or vertigo

Nose: Positive for rhinitis.

Throat: Negative for hoarseness, negative for pain on swallowing. Positive for erythema.

Respiratory: Patient reports cough began 3 days ago. Denies generalized shortness of breath and denies SOB with exertion.

Breasts: Patient denies Pain, lumps, or nipple changes

Cardiovascular: Denies any chest pain, denies history of chest pain, heart murmur, palpitations, dyspnea, activity intolerance.

GI: Denies nausea, vomiting, diarrhea or constipation. Denies change in bowel habits, blood in stool. Denies abdominal pain. Musculoskeletal: Denies flank pain, joint pain, muscle pain and decrease in range of motion.

Neurologic: negative for seizure, alert and oriented. Denies change in sensation, no tingling, and numbness.

Endocrine: Denies heat/cold intolerance, polyuria, polydipsia, polyphagia or glandular/hormonal problem. Denies any dryness of the skin.

Hematological: Denies easy bruising or bleeding. Denies any malaise, denies night sweats, tenderness in the nodes of the neck or groin area.

Integumentary: Denies, lesions, rashes, itching, or bruising.

GU: Denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence, hematuria, history of stones.

Psychiatric: Denies depression, hopelessness, anxiety.

Objective

Physical assessment: Blood pressure: 118/70 mm, Hg, Heart rate: 85 bpm, Temperature: 98.6°F

Respirations: 20 per minute.

Height: 5’6’’inches

Weight: 155lbs

Appearance: Patient appears well nourished. Patient noted sitting upright, patient speech is appropriate for age of a 22 year old. Well appearing, communicates in context.

HEENT: Head noted normocephalic, atraumatic. Pupils are equal, round, reactive to light and accommodation (PERRLA). Conjunctiva pink. Ears noted equal in size bilaterally – Left ear canal clear, tympanic membrane pearly gray. Right ear canal clear, tympanic membrane pearly gray. No redness, fluid, or bulging noted. Hearing is intact bilaterally. External appearance normal-no lesions, redness, or swelling.

Nose: Positive for Rhinitis and congestion. Nose symmetric, no septal defects noted, pink turbinates, no mucous, inflammation, or lesions present. No maxillary or frontal sinus tenderness noted. Lips appear moist, moist mucous membranes.

Mouth: Throat examination reveals mild erythema but no exudates.

Neck: Neck is supple with trachea at midline; some difficulty swallowing notes, and the thyroid is non-tender on palpation. No lymphadenopathy noted.

Cardiovascular: Patient’s skin is consistent with race without paleness or mottling of the face or hands. Normal rate/rhythm – no adventitious sounds noted. No murmurs present. Apical pulse regular. No carotid bruits noted. Capillary refill is <3 seconds. No Jugular Vein distention noted. Positive and strong radial, ulnar, brachial, femoral, popliteal, dorsalis pedis and posterior tibial pulses.

GI: Abdomen soft, nontender/ nondistended. Bowel sounds noted and normoactive in all four quadrants. No rigidity or guarding, no organomegaly noted.

Pelvic/GU/Rectal: No bladder distention, no suprapubic pain.

Musculoskeletal: Denies any limitation of motion. Joint stability normal. No tenderness on palpation of lower back and flank area. No tenderness to his bilateral upper and lower extremities. Normal range of motion and a steady gait.

Psych- Bright, alert, appropriate and cooperative with examination. The patient's appearance is well kept. Patient appears happy/content.

Neuro: Alert and oriented x3. 5/5 strength and tone on all four extremities. Deep tendon upper and lower reflexes +2 bilaterally. Denies weakness, convulsions/seizures, migraines, numbness, decreased in cognitive skills, loss of balance, head injuries or tremors.

Pulmonary: No signs of respiratory distress. Lungs clear to auscultation, no wheezing, no rales, no crackles noted.

Assessment:

Differential Diagnosis:

The patient's clinical assessment confirms a diagnosis of Allergic Rhinitis (J30.4). Allergic Rhinitis is a response from a trigger which causes inflammation or a triggered response (Chung et al., 2022). The 22 year old patient came in with a persistent cough for the past three days. Reports that the cough is worse at night with a runny nose. There have been no reports of fever, chills or nausea. All of these reports proves diagnosis of allergic rhinitis.

Plan:

Diagnosis Allergic Rhinitis (J30.4)

Plan

Medication:

· Cetirizine 10mg, twice daily

Education:

· Analyze the anticipated progression of viral infections.

· Provide details regarding ways for managing allergies.

· Exhibit correct utilization of the inhaler if it has been prescribed

· Humidifier use at night

· Encourage rest and adequate fluid intake.

· Saline nasal drops as needed.

Health Maintenance:

Blood Pressure Measurement: Blood pressure measurements may be routinely taken during preventive healthcare visits to identify and address potential hypertension or pre-hypertension.

Immunizations: The USPSTF endorses the Centers for Disease Control and Prevention (CDC) immunization schedules, which include vaccinations to protect against various diseases, such as HPV, meningococcal disease, and influenza.

RTC: Patient has been instructed to return to the clinic for a follow-up evaluation in a 7-10days. Patient verbalized understanding. Patient was sent home.

References

Chung, K. F., McGarvey, L., Song, W. J., Chang, A. B., Lai, K., Canning, B. J., ... & Mazzone, S. B. (2022). Cough hypersensitivity and chronic cough. Nature Reviews Disease Primers, 8(1), 45.

Kantar, A., Marchant, J. M., Song, W. J., Shields, M. D., Chatziparasidis, G., Zacharasiewicz, A., ... & Chang, A. B. (2022). History taking as a diagnostic tool in children with chronic cough. Frontiers in pediatrics, 10, 850912.

Masson, V., Kier, C., & Chandran, L. (2022). Cough conundrums: A guide to chronic cough in the pediatric patient. Pediatrics In Review, 43(12), 691-703.

U.S. Preventive Services Task Force. (n.d.). USPSTF A and B Recommendations. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations.