Soap Note Patient Assessment Medical Documentation Example White Paper

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Episodic/Focused SOAP Note


Patient Information


C., 28 years, Female, Caucasian


S.
CC (chief complaint): Runny nose and itchy eyes.
HPI: 28-year-old Caucasian female experiences a runny nose and itchy eyes every spring. The symptoms usually last between six and eight weeks. Current episode has lasted for 9 days and characterized by on and off sneezing and a tickle on the throat. Claritin gives her relief but does not make her completely better. Symptom severity is 7/10 pain scale.
Current Medications: None.
Allergies: No known allergies.
PMHx: No previous hospitalizations for any ear, nose and throat disorders. No trauma or surgeries to date. The patient is up-to-date on immunizations with the last tetanus immunization on 02/2022.
Soc Hx: Patient was born and raised in Hoboken, NJ. She lives with her husband and works as a Sales Manager at a local retail store. Her home and workplace has a working smoke detector. While she drinks alcohol and smokes at least twice a week, she exercises regularly.
Fam Hx: Her father, aged 55 has no significant medical history while her mother, aged 47 has a history of hypertension. Her two siblings have no significant medical history. Her maternal grandmother died aged 76 with a history of hypertension and her paternal grandfather dies aged 82 with a history of Type II diabetes. Her paternal grandmother and maternal grandfather are still alive with a history of high blood pressure and Type II diabetes respectively. The rest of her family members like uncles and aunts have no significant medical history.

ROS:


GENERAL:  Alert and oriented; no fever; no weakness, fatigue, weight gain or loss, denies any change in appetite.

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HEENT:  Eyes: Itchy eyes; denies visual loss or blurred vision. Ears, Nose, Throat:  Ears feel full; denies hearing loss; sneezing (on and off); runny nose; a tickle on the throat.
SKIN:  No rashes; no changes in skin; no skin…

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…congestion, itchy nose, eyes, and throat and ear fullness (Small, Keith & Kim, 2018). This condition is essentially an allergic reaction to tiny particles in the air and can last several weeks on longer. The patient’s symptoms are the classic signs of this condition and are seasonal i.e. during spring.
2. No other significant health problems or concerns.

Differential Diagnoses


· Chronic rhinosinusitis. According to Wheatley & Togias (2015), allergic chronic rhinosinusitis is one of the differential diagnoses of allergic rhinitis. The patient could be diagnosed with allergic chronic rhinosinusitis because of nasal congestion and nasal drainage that last for at least 12 weeks every spring.
· Seasonal rhinitis. This condition could be applicable to the patient because her symptoms usually occur every spring. Quillen & Feller (2006) contend that seasonal rhinitis is a differential diagnoses of allergic rhinitis that applies to patient whose symptoms are seasonal and include watery/itchy eyes, ear fullness, nasal congestion, and excessive mucus production.
· Perennial….....

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