Reply to Health Assessment wk 4

  Please write a 300 word reply to my classmate, her discussion post is below. APA format. NO AI. My professor is a stickler for AI. PLEASE NO AI. scholarly written, APA formatted and a minimum of 3 references (which may include the course textbook).  Please write pros and cons to the classmates SOAP note. Please write abput things you would add or take away.

 

NSG 500
SOAP Note Template

Patient initials: TJ
Age: 28
Date of Encounter: 6/10/26
Historian: Patient (reliable)
Time of Encounter: 0800
Limitations: None

SUBJECTIVE

Chief Complaint: Sore throat, itchy eyes, and runny nose for one week.

HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of a sore, itchy throat, itchy eyes, and runny nose for the last week. She states these symptoms began spontaneously and have remained constant in nature. She reports that her throat pain is worse in the morning and rates the pain as 4/10 and throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges, which have provided mild relief. She reports mild discomfort when swallowing but denies other associated symptoms. She states her nose "runs all day" with clear drainage and has not attempted treatment for nasal symptoms. She reports persistent eye itching and redness without treatment. She denies cough, recent illness, exposure to sick contacts, changes in hearing, taste changes, fever, chills, or night sweats. She has never been diagnosed with seasonal allergies but reports her sister has a history of hay fever.

Past Medical History: Asthma diagnosed during childhood. Last asthma-related hospitalization occurred at age 16. Uses albuterol inhaler approximately 2–3 times weekly. Known allergies to cats and dust. Denies previous HEENT disorders, recurrent streptococcal infections, chronic sinus disease, hearing disorders, vision disorders requiring corrective lenses, or head trauma.

Past Surgical History: None reported.

Social History: Denies tobacco, alcohol, and illicit drug use. Denies known environmental exposures or irritants. Changes bed linens weekly and denies dust or mildew concerns within the home. Does not participate in routine exercise.

Family History: Sister with history of seasonal allergies ("hay fever"). Otherwise denies significant family history related to current complaint.

Allergies: Penicillin (rash/hives), cats, dust.

Medications:

• Albuterol sulfate inhaler, 2 puffs inhaled as needed for asthma symptoms.
• Over-the-counter throat lozenges as needed.

Review of Systems:

Head: Reports occasional headaches while studying. Denies head trauma, dizziness, or lightheadedness.

Eyes: Reports itchy, red eyes and intermittent blurry vision after prolonged reading. Denies eye pain, excessive tearing, or corrective lens use.

Ears: Denies hearing loss, tinnitus, vertigo, ear pain, or ear discharge.

Nose/Sinuses: Reports clear rhinorrhea for one week. Denies epistaxis, nasal congestion, sinus pressure, sinus pain, sneezing, or changes in smell.

Mouth/Throat: Reports sore and itchy throat with mild discomfort when swallowing. Denies hoarseness, oral lesions, gum disease, dry mouth, or changes in taste.

Neck: Denies neck pain, swollen glands, thyroid disease, or voice changes.

OBJECTIVE

Vital Signs:
Temperature: 99.1°F
Blood Pressure: 141/82 mmHg
Pulse: 80 bpm
Respirations: 16 breaths/min
SpO₂: 99% on room air

General: Alert, oriented, pleasant 28-year-old African American female in no acute distress.

HEENT: Head normocephalic and atraumatic with symmetrical facial features. Bilateral allergic shiners present. Conjunctivae mildly injected; sclerae white. Pupils equal, round, and reactive to light and accommodation. Extraocular movements intact. Visual acuity 20/20 left eye and 20/40 right eye. Auditory canals pink and patent bilaterally. Tympanic membranes pearly gray, intact, with visible landmarks bilaterally. Weber, Rinne, and whisper tests normal. Nasal mucosa pale and boggy with clear drainage present; septum midline. Frontal and maxillary sinuses nontender to palpation. Oral mucosa moist and pink. Posterior oropharynx mildly erythematous with cobblestoning and clear postnasal drainage. Tonsils 1+ bilaterally without exudate. Uvula midline.

Neck: Supple and symmetric without masses or swelling. No cervical lymphadenopathy. Thyroid smooth without enlargement or nodules. Full range of motion without discomfort.

CV: Carotid pulses 2+ bilaterally without bruits.

Resp: Respirations even and unlabored. Lung sounds clear to auscultation bilaterally.

Musculoskeletal: Jaw with full range of motion without popping or clicking.

Neurological: Alert and oriented ×3. No focal deficits noted.

Skin: Acanthosis nigricans noted on neck. Skin otherwise warm, dry, and intact.

Psychiatric: Appropriate mood and affect. Maintains eye contact and responds appropriately throughout examination.

Diagnostics:
No laboratory or diagnostic testing indicated at this time. Diagnosis is supported by history and physical examination findings. Referral for comprehensive ophthalmologic examination is recommended due to decreased right eye visual acuity (20/40) (Pagana et al., 2022).

ASSESSMENT

Primary Diagnosis:
Allergic Rhinitis (J30.9)

Rationale:
The patient's presentation is most consistent with allergic rhinitis. Supporting findings include itchy eyes, clear rhinorrhea, sore and itchy throat, allergic shiners, pale boggy nasal mucosa, postnasal drainage, and posterior pharyngeal cobblestoning. These findings are characteristic of allergic inflammation of the upper airway and nasal passages and are commonly associated with environmental allergen exposure (Cheng et al., 2025; MedlinePlus, 2024).

Differential Diagnoses:

1. Viral Upper Respiratory Infection (Common Cold) – Considered due to sore throat and rhinorrhea. However, the patient denies fever, cough, malaise, and recent sick contacts, making this diagnosis less likely (MedlinePlus, 2024a).
2. Acute Sinusitis – Considered due to nasal drainage and throat irritation. However, the patient denies facial pain, sinus pressure, and nasal congestion, and frontal and maxillary sinuses were nontender on examination, making this diagnosis less likely (MedlinePlus, 2024b).

PLAN

Nonpharmacologic:
• Educate patient regarding avoidance of known allergens, including cats and dust exposure.
• Encourage increased hydration.
• Recommend saline nasal spray or nasal irrigation for symptom relief.
• Encourage monitoring of symptom patterns and identification of environmental triggers. (Noreña-Peña et al., 2025).

Pharmacologic:
• Initiate loratadine (Claritin) 10 mg orally once daily as needed.
• Continue throat lozenges as needed for throat discomfort.
• Antihistamines remain a first-line treatment option for management of allergic rhinitis symptoms (MedlinePlus, 2024).

When to Seek Emergency Evaluation:
• Difficulty breathing or wheezing not relieved by inhaler.
• Facial swelling or signs of severe allergic reaction.
• High fever, worsening symptoms, or significant visual changes.

Follow-Up:
• Follow up in 2–4 weeks if symptoms persist or worsen.
• Recommend routine ophthalmologic evaluation due to decreased visual acuity in the right eye.
• Persistent symptoms despite standard therapy may require additional evaluation and consideration of advanced treatment options (Cheng et al., 2025).

References

Cheng, X., Zhou, Y., Hao, Y., Long, Z., Hu, Q., Huo, B., Xie, T., Chen, S., Zhou, L., Zhou, T., 

Li, L., Cheng, Q., & Chen, J. (2025). Recent studies and prospects of biologics in allergic rhinitis treatment. International Journal of Molecular Sciences, 26(10), 4509. https://doi.org/10.3390/ijms26104509

MedlinePlus. (2024). Allergic rhinitis. https://medlineplus.gov/ency/article/000813.htm

MedlinePlus. (2024a). Common cold. https://medlineplus.gov/ency/article/000678.htm

MedlinePlus. (2024b). Sinusitis. https://medlineplus.gov/ency/article/000647.htm

Noreña-Peña, A., Borque, F. M., Mestre-Ferrandiz, J., Olmo, J. D., Gil-Guillén, V. F., Pacheco, 

R. R., Rizo-Baeza, M. M., & Cortés-Castell, E. (2025). Patient expectations in allergic rhinitis treatment: A mixed-methods study. Patient Preference and Adherence, 19, 3307–3322. https://doi.org/10.2147/PPA.S526348

Pagana, K. D., Pagana, T. J., & Pagana, T. N. (2022). Mosby's diagnostic and laboratory test 

reference (16th ed.). Elsevier.