Studocu is not sponsored or endorsed by any college or university

Heent SOAP note-Tina Jones

Adv Practice Nursing I (William Paterson University)

Studocu is not sponsored or endorsed by any college or university

Heent SOAP note-Tina Jones

Adv Practice Nursing I (William Paterson University)

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HEENT SOAP note

SUBJECTIVE

Chief Complaint

“My throat has been sore…and itchy. And my nose won’t stop running.” “My itchy eyes, runny

nose, and sore throat all started a week ago.”

HPI (History of Present Illness)

Ms. Jones is a twenty-eight-year-old African American woman who comes to the clinic

complaining of a sore, itchy throat, itchy eyes, and runny nose for the last week. She has stated

that the symptoms started abruptly and have been constant. She has no complaints of any other

aggravating symptoms but states that her throat pain is worse in the morning. She rates the throat

pain as a 4/10 and her throat itchiness as a 5/10. She states that the itchiness and soreness are

present in the back of the throat and that it does not radiate to any other place. She has treated her

throat pain with occasional throat lozenges every few hours and with drinking water which has

helped her a little bit. She states that she has some soreness with swallowing but states no other

aggravating symptoms. She has also stated that she has a runny nose that “runs all day” and

produces a clear discharge. She has not done any nasal treatments for her nose and states that

“most of the stuff you get over-the-counter dries [her] out too much”. She also states that her

eyes are constantly itchy and that they have been red. She states that it feels like how it does

when she is around cats, but she has not been around cats recently. She denies taking anything to

help soothe her itchy eyes. She denies cough, or any recent illnesses and she states that she has

had no exposure to sick individuals. She denies fevers, chills, or night sweats. She has never

been diagnosed with any seasonal allergies but has stated that her sister has hay fever.

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PMH (Pertinent past medical history)

Ms. Jones has a history of asthma but has not had a severe attack since she was in high school.

Medications

 Proventil inhaler 90 mcg/spray MDI

o Takes two puffs, sometimes three puffs PRN for wheezing related to asthma. She

uses it about two-three times out of the week.

 Acetaminophen 500 mg

o Takes one-two gel capsule by mouth PRN for headaches. She states that she takes

it once a week or less

 Ibuprofen 200 mg

o Takes three pills by mouth TID PRN for menstrual cramps

 Halls throat lozenges

o Takes 5-6 a day PRN for sore throat. The patient is unsure of the dosage

Allergies

The patient reports that she is allergic to penicillin and that when she took it when she

was younger it caused her to have rash and hives. She denies having any food, latex, or seasonal

allergies. She has expressed having an allergy to cats and dust. When exposed to cats and dust

the patient has expressed that she experiences itchy eyes, sneezing, and increased asthma

symptoms.

Pertinent Family History, Social History, and other subjective data if relevant to the

patient’s presenting problem and diagnosis.

Ms. Jones denies the use of tobacco and illicit drugs. She states that she drinks alcohol

socially with friends and usually drinks about two-three drinks when she is out. She is not aware

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of any environmental exposures or irritants at her job or at home. She changes her sheets weekly

and denies dust/mildew at her house. Her sister has a history of “hay fever”

ROS (Pertinent review of systems)

 General denies changes in appetite, fatigue, weakness, fever, chills, and night sweats.

 Head- denies history of trauma, reports headaches while studying

 Eyes- denies wearing glasses or contacts, but notes that her vision has been getting worse

over the past few years. Complains of blurry vision after reading for extended periods.

Denies any itching, tearing, or redness before last week.

 Ears: denies vertigo, discharge, earache, or hearing loss.

 Nose/sinuses deny sneezing, itching, and rhinorrhea before this episode. Denies previous

allergy, or sinus pressure.

 Mouth/throat denies bleeding gums, swollen lymph nodes, wounds in the mouth, or

hoarseness. Denies having a sore throat before this episode.

 Respiratory: Denies SOB, wheezing, coughing. She has a past medical history of asthma

and her last hospitalization was due to an asthmatic attack when she was in high school.

OBJECTIVE

Tina Jones is 5’6 weighing 195.8 lbs. with a BMI of 30.8. She has presented to the

facility with her random blood glucose level being 199, a temperature of 99.1°F, blood pressure

of 141/82, heart rate of 80, respiratory rate of 16, and her O2 level at 99%.

Physical Examination

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 General- Ms. Jones is a twenty-eight-year-old African American woman in no acute

distress. She is awake, alert, and oriented times three and maintained eye contact

throughout the interview and examination.

 Head: normocephalic and atraumatic, with no signs of masses on the scalp, and hair is of

normal distribution.

 Eyes: Bilateral eyes equal in hair distribution with no lesions and no edema. Conjunctiva

moist and pink with no discharge and sclera injected. Pupils are equal, round, and

reactive to light bilaterally. Convergence normal. The left fundoscopic exam showed

sharp disc margins with no hemorrhages. The Right fundoscopic exam cotton wool

bodies but had sharp disc margins. Left eye vision: 20/20 and right eye vision: 20/40.

 Ears: Ears bilaterally equal and external canals without inflammation. Tympanic

membranes are pearly grey and intact with positive light reflex. Rinne, Weber, and

Whisper test reported normal results bilaterally.

 Nose: Septum midline, nasal mucosa bilaterally boggy and pale. No pain was indicated

with palpation of frontal and maxillary sinuses.

 Mouth/Throat: Moist buccal mucosa with no wounds visualized. Dental hygiene adequate

with uvula midline. Tonsils 1+ without evidence of inflammation. Posterior pharynx

slightly erythematous with mild cobblestoning

 Neck: No cervical, infraclavicular lymphadenopathy. Thyroid smooth without nodules or

goiter. Acanthosis nigricans present. Carotid arteries +2 with no thrill present. No clicks

are present in the jaw, full range of motion is present. Carotid arteries were auscultated

bilaterally with no bruit present.

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 Respiratory: Chest symmetrical with respirations. Lung sounds clear to auscultation

without wheezes, crackles, or cough.

ASSESSMENT

Differential Diagnosis

Acute viral Rhinitis- ICD10- Code J30.9

Viral rhinitis is a common upper respiratory tract infection that is caused by a large

family of viruses and is one of the more difficult diagnosing exercises for a practitioner. Some

symptoms that are usually present within the patient are, mucus production, rhinorrhea, nasal

blockage, sneezing, and itchy nose/eyes (Catli et al, 2019). Upon physical examination, the

patient will typically present with a pale face, watery nose/eyes, reddish nose tip, blocked nasal

passage, accompanying conjunctivitis, and cervical lymphadenopathy. The diagnostic test would

be the same for allergic rhinitis and acute viral rhinitis. The testing that would be used would be

an allergy test such as a skin prick test. In this test, the patient would be pricked on the finger

with a needle of an allergen, and if a reaction occurred it would conclude that it is allergic rhinitis

versus acute viral rhinitis. (Birch & Pearson-Shaver 2021).

Vasomotor rhinitis-ICD10-Code J30.0

Vasomotor rhinitis is one of the most common forms of non-allergic rhinitis. Symptoms

that are usually present in this disease process are headache, facial pressure, postnasal drip,

coughing, throat clearing, and nasal congestion or rhinorrhea. (Leader& Geiger, 2022). Upon

physical examination, the patient will typically present with a boggy edematous mucosa with

clear mucoid secretions. Mucosal injection, lingual tonsils, and the absence of purulent drainage.

(Leader& Geiger, 2022). The diagnostic testing that would rule out vasomotor rhinitis and

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allergic rhinitis would again be a skin prick test and based upon whether the patient reacts to one

or the other will determine whether or not one or the other is present.

Working Diagnosis Allergic rhinitis-ICD10- Code J30

Ms. Jones came to the office complaining of a sore, itchy throat, itchy eyes, and a runny

nose that is constant. An individual will typically be exposed to one or two of these symptoms

when they come into contact with allergens such as pollen, dust, plants, foods, and animals.

(Goolsby & Grubbs,2019,p.169). Typical physical examination findings that support the

diagnosis of allergic rhinitis include a boggy and pale mucosa, clear and watery nasal discharge,

cobblestone look to the posterior pharynx, and ear congestion could also be present as well.

(Goolsby & Grubbs,2019,p.169).

References:

Birch, K., & Pearson-Shaver, A. L. (2021, July 30). Allergy testing. National Library of

Medicine. Retrieved May 29, 2022, from

https://www.ncbi.nlm.nih.gov/books/NBK537020/

Çatlı, T., Atilla, H., & Miller, E. K. (2019, May 14). Acute viral rhinitis. All Around the Nose:

Basic Science, Diseases and Surgical Management. Retrieved May 29, 2022, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7123171/#:~:text=Generally%2C

%20acute%20rhinitis%20is%20associated,such%20as%20winter%20or%20fall.

Goolsby, M. J., & Grubbs, L. (2019). Ear, Nose, Mouth, and Throat. In Advanced assessment:

Interpreting findings and formulating differential diagnoses (4th ed., pp. 168–169). essay,

F.A. Davis Company.

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Leader , P., & Geiger, Z. (2021, May 1). Vasomotor Rhinitis. National Library of Medicine.

Retrieved May 29, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK547704/#article-

31035.s5

Working diagnosis Allergy rhinitis – ICD-10-
Code J30.1 Pt.
complained of a sore, itchy throat, itchy
eyes, and running nose.
According to Cleveland clinic (2020),
someone would experience
or more of these symptoms when in contact
with allergens such
pollen, mold, or pet dander. Typical PE
findings that support the
diagnosis of allergic rhinitis includes: clear
nasal drainage, bogg
mucosa, pharyngeal cobblestoning, and eye
itching(Rhoads and
Petersen, 2021)

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Working diagnosis Allergy rhinitis – ICD-10-
Code J30.1 Pt.
complained of a sore, itchy throat, itchy
eyes, and running nose.
According to Cleveland clinic (2020),
someone would experience
or more of these symptoms when in contact
with allergens such
pollen, mold, or pet dander. Typical PE
findings that support the
diagnosis of allergic rhinitis includes: clear
nasal drainage, bogg
mucosa, pharyngeal cobblestoning, and eye
itching(Rhoads and
Petersen, 2021)

Working diagnosis Allergy rhinitis – ICD-10-
Code J30.1 Pt.
complained of a sore, itchy throat, itchy
eyes, and running nose.
According to Cleveland clinic (2020),
someone would experience
or more of these symptoms when in contact
with allergens such
pollen, mold, or pet dander. Typical PE
findings that support the

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diagnosis of allergic rhinitis includes: clear
nasal drainage, bogg
mucosa, pharyngeal cobblestoning, and eye
itching(Rhoads and
Petersen, 2021)

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