Episodic Soap Note Comprehensive Solved Nursing Essay Example

Episodic Soap Note Comprehensive Solved Nursing Essay Example

Patient Information:

R, 50, Male, Race

Subjective

CC:  “Nasal Congestion” and “5-day itching nose”

HPI: Richard is a 50-year-old male complaining of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. The patient’s nose, eyes, palate and ears have been itchy for the past five daya. He is alert and oriented x 3. The patient is taking Mucinex OTC to aid breathing with less significant effects. Besides, the patient has no headache or pain. The patient’s ears and throat are red and inflamed. The patient is pale, has watery nasal mucosa with thin and clear secretions. Turbinates are enlarged. (Episodic Soap Note Comprehensive Solved Nursing Essay Example)

Current Medications: Mucinex OTC 1 tab orally every night.

Allergies: NKDA

PMHx: Hypertension

Soc Hx: Married, three children aged 25, 21 and 17. Occasionally drink alcohol. Nonsmoker. Routine exercise and healthy diet.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)

Fam Hx: Parents diseased. Wife and children are all alive and healthy.

Reviews of Systems:

GENERAL:  Well dressed, No fever, chills or fatigue. Alert and oriented x3.

HEENT:  No headaches. Itchy and red eyes. PERRLA, vision is intact. Hearing intact, red and inflamed throat, pale and watery nasal mucosa with thin secretions. Tonsils normal.  Throats appear erythematous.

Neck: Trachea is well positioned Lymph node not swollen.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)

Skin: No itchy or skin rash. Skin color intact. Normal skin turgor.

CARDIOVASCULAR:  No pain in the chest area. No chest pressure or discomfort. No edema of palpitations.

RESPIRATORY:  No cough, dyspnea, or phlegm.

GASTROINTESTINAL:  No nausea, anorexia, constipation, vomiting or diarrhea. No heartburn or abdominal pain.

NEUROLOGICAL:  Itchy and red eyes. Sense of smell, hearing and taste intact. No headache or dizziness.

MUSCULOSKELETAL:  No joint, back or muscle pain/stiffness.  Denies muscle weakness.

LYMPHATICS: Normal nodes.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)

PSYCHIATRIC:  No history of psychological disorder.

ENDOCRINOLOGIC:  No frequent urination or polydipsia.

ALLERGIES:  Seasonal allergies. NKDA.

Objective

General: AAO x 4, denies weakness, denies fatigue, well groomed, well nourished.

V/S: Temp: 99F, P: 72, R: 15, BP: 123/79, Wt: 185 lbs, Ht: 5”9”

HEENT: No headaches. Itchy and red eyes. PERRLA, vision is intact. Hearing intact, red and inflamed throat, pale and watery nasal mucosa with thin secretions. Tonsils normal.  Throats appear erythematous.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)

C/V: No pain in the chest area. No chest pressure or discomfort. No edema of palpitations.

Extremities: Normal breathing, Joints are symmetrical. Regular pulse and heartbeat.

Skin: Non itchy, no rashes, good turgor, rough, dry, and yellowing skin.

Respiratory:  No cough, dyspnea, or phlegm.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)

Musculoskeletal:  No joint, back or muscle pain/stiffness.  Denies muscle weakness.

Lymphatics: Normal nodes.

Allergies:  Seasonal allergies. NKDA.

Diagnostic results:

Skin Test: positive to pollen.

Skin tests are done to diagnose seasonal reactions to pollen (Delves, 2016).

Allergen-specific IgE antibody testing: Not done.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)

Use to identify if a medication is causing allergic reactions (Quillen & Feller, 2006)

Assessment.

Differential Diagnoses:

1. Allergic rhinitis: Symptoms include sneezing, obstruction of the airflow, inflammation reaction and nasal congestion (Delves, 2016). Other symptoms include itchy nose, eyes or skin throat irritation, cough and fatigue.
2. Rhizovirus: Viral infection of the respiratory tract. Symptoms include sore throat, facial pressure, cough and loss of smell/taste (Ball et al., 2015). A patient can also suffer swollen eyes causing headaches.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)
3. Sinusitis: Symptoms include obstruction of the nasal cavity, congestion rhinorrhea, facial pressure/pain and headache (Marvin, 2017). A patient can also loos sense of smell or taste, fatigue or anterior discharge.
4. Sore throat: Painful posterior pharynx during swallowing. Symptoms include enlarged tonsils, and painful posterior pharynx (Marvin, 2016). A patient can also have pus from the tonsils, or scratchy throat sensation.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)
5. Acute sinusitis: Caused by bacterial infection and symptoms include nasal discharge with pus and loss of sense of smell (Petersen, 2016). Also, the patient can have a nasal blockage or drip.(Episodic Soap Note Comprehensive Solved Nursing Essay Example)

 References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s Guide to Physical Examination-E-Book. Elsevier Health Sciences.

Delves, P. J. (2016). Allergic Rhinitis. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/allergic-rhinitis#v6515770

Marvin, P. F. (2016). Sore Throat. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-tothe-patient-with-nasal-and-pharyngeal-symptoms/sore-throat

Petersen, S. W. (2016). Advanced health assessment and diagnostic reasoning. Jones & Bartlett Learning.

Quillen, D. M., & Feller, D. B. (2006). Diagnosing Rhinitis: Allergic vs. Nonallergic. American Family Physician, 73(9), 1583-1590. Retrieved from https://www.aafp.org/afp/2006/0501/p1583.html