Tina Jones Shadow health – SOAP Note- HEENT

ID: Tina Jones is an obese 28-year-old African American, who presents to the clinic today with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week.

S. CC: “My throat has been sore…and itchy. And my nose won’t stop running. These symptoms are driving me nuts.”

HPI:
Onset: “a week ago”
Location: Throat and nose
Duration: One week
Characteristics: “sore and itches a lot, in the back”,” clear” discharge from nose, no congestion, no fever, no earache, no chills, no fatigue, no nausea
Aggravating Factors: “it’s a little worse in the morning, but that’s really the only pattern I’ve noticed.”
Relieving Factors: Throat drops, “drinking more water”
Treatment: Over the counter throat drops

PMHx:

Tina Jones Shadow health assessment

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Asthma: Diagnosed at 2 ½ years old, last hospitalized “in high school”, never intubated, takes Proventil, 2-3 times per week. Type II Diabetes Mellitus: Diagnosed at 24 years old, previously took Metformin, 500mg BID, stopped taking stating the pills made her “gassy…it was overwhelming, taking pills and checking my sugar”, never hospitalized, she does not monitor her blood sugar. Hypertension: Discussed elevated BP at last visit, educated pt. on diet and exercise prior to medication to try and decrease BP. Immunizations: Tetanus and booster received within
the last year, denies flu vaccine, COVID-19 vaccine received, “believes” she is up to date on childhood immunizations.

Family Hx: Mother- age 50, HTN, elevated cholesterol,
•Father- deceased in car accident one year ago, HTN, high cholesterol, T2DM,
•Brother- overweight
•Sister: asthma, hay fever
•Maternal grandmother: died at age 73 of a stroke, hx of HTN, high cholesterol
•Maternal grandfather: died at age 78 of a stroke, hx of HTN, high cholesterol
•Paternal grandmother: still living, age 82, HTN
•Paternal grandfather: died at age 65 of colon cancer, hx of type 2 diabetes
•Paternal uncle: alcoholism
•Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Habits: No tobacco. Occasional cannabis uses from age 15 to 21. Reports no use of illicit drugs. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than three drinks per episode. She drinks four diet sodas a day.

Medications: Proventil inhaler, 90mcg, 2-3 puffs, Pt uses 2-3 x a week, Tylenol PO, 500mg, prn for headaches, Advil PO, 200mg TID prn for cramps, throat lozenges prn for sore throat

Allergies:

•Cats- runny nose, itchy and swollen eyes, and asthma exacerbation
•Dust and pollen- sneezing, asthma exacerbation
•Penicillin- rash

Soc Hx:

Tina Jones Shadow health – SOAP Note

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Never married, no children. Currently single, last monogamous relationship two years ago. Lives with mother and sister in a single-family home to support family after death of father one year ago. Employed as a supervisor at Mid-American Copy and Ship. She is a part-time student, earning her bachelor’s degree in accounting. She enjoys spending time with her friends, attending and volunteering at her church. Has smoke detectors in home, wears seatbelt. Does not wear sunscreen. Guns locked up in residence.
ROS

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CONSTITUTIONAL: No weight loss, fever, chills, weakness, or fatigue

HEENT: Eyes: No visual loss, C/O watery, itchy eyes, blurriness when reading, getting worse.
No double vision. Denies ear pain, changes in hearing, hearing loss, or feeling of ear congestion.
Nose: reports “clear” drainage. Throat: itchy, pain 4/10 when swallowing, worse in the morning, denies neck pain, denies swollen glands.

Respiratory: denies hx of pneumonia or chronic bronchitis

Cardiovascular: denies palpitations or irregular heartbeat, denies peripheral edema

Gastrointestinal: denies nausea, vomiting, diarrhea. Reports polydipsia, polyphagia for past few months.

Genitourinary: denies flank pain, cloudy urine, denies hx of UTI or kidney infections. Denies
vaginal discharge. No hx of pregnancy. Menses irregular. No hx of STIs.

Musculoskeletal: denies hx of fractures. Denies generalized weakness. Denies fainting, dizziness, seizures. Denies hx of changes in memory.
Skin, hair, and nails: Reports acne and occasional dry skin. Complains of darkened skin around her neck and increase in facial and body hair. She reports a few moles.

Hematologic: No hx of anemia and pt. denies bleeding or bruising easily.

Lymphatics: No enlarged nodes. No hx of splenectomy. No surgical hx.

Psychiatric: No hx of depression or anxiety. Felt “sad” after father’s death, denies feeling sad now, denies ever feeling suicidal.

Endocrinologic: No reports of sweating, cold or heat intolerance.

O. Vital Signs:

Physical Exam:

General Appearance: Pleasant, obese, African American woman in no acute distress.

HEENT:

Head: normocephalic, scalp atraumatic and symmetrical.

Eyes: no lesions or edema, conjunctiva pink & moist, PERLA; with ophthalmoscope exam, sharp disc margins, no hemorrhages, left eye 20/20; right eye 20/40; no extraocular movements or nystagmus noted.

Ears: bilateral ear canals pink with pearly gray tympanic membranes and positive light reflex; no visual discharge or bulging bilaterally; normal Weber, Rinner, and whisper tests.

Nose: red, chapped skin under nares; nasal cavity pale bilaterally; patent with clear drainage; no pain with palpation to frontal or maxillary sinuses.

Mouth: pink, moist, tonsils 2+ with erythema and with cobble stoning noted in posterior oropharynx and clear post-nasal drip; uvula midline; no visualized wounds or dental carries; positive gag reflex.

Neck: thyroid smooth without goiter or lesions, not tender with palpation; acanthosis nigricans present.

Lymph Nodes: no cervical or supraclavicular lymphadenopathy.

Chest: symmetrical with respirations; lung sounds clear to auscultation; no adventitious sounds noted.

Cardiac: temporal and carotid pulses 2+ with no bruits or thrills noted.

Abdomen: not assessed at this time. Genitourinary: not assessed at this time. Skin: not assessed at this time.

Musculoskeletal: not assessed at this time.

Neurologic: alert & oriented x3.

Psychiatric: maintains good eye contact during exam.

A: Allergic Rhinitis (AR)
Sneezing, nasal pruritis, airflow restriction, and clear nasal discharge are all symptoms of allergic rhinitis, which is caused by IgE-mediated responses to inhaled allergens and involves mucosal inflammation mediated by type 2 helper T (Th2) cells (Wheatley & Togias, 2015). Seasonal pollens and molds, as well as persistent indoor allergens including dust mites, pets, vermin, and certain molds, are important allergens. A familial history of allergic rhinitis or a personal history of asthma is common in these people (Varshney & Varshney, 2015). Providers may detect mouth breathing, frequent sniffling and/or throat clearing, a transverse supra-tip nasal crease, and dark circles under the eyes during a physical examination. Anterior rhinoscopy usually indicates nasal mucosa edema and thin, clear secretions. The inferior turbinates may be blue in color, and nasal mucosa cobblestoning may be present (Varshney & Varshney, 2015).

Differential Diagnosis: Acute sinusitis, common cold

PLAN:

Tina Jones Shadow health Assignment

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Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit.

  • Initiate trial of loratadine (Claritin) 10mg PO daily

Antihistamines of the first and second generations are both effective in reducing AR symptoms. Due to its propensity to penetrate the blood-brain barrier, first-generation antihistamines can be quite sedating. Second-generation antihistamines are more selective for H1 receptors, less sedating, and have longer half-lives (12-24 hours) than first-generation antihistamines (Wise et al., 2018).

  • Encourage increase of water intake and other fluids
  • Educate on proper handwashing
  • Educate on avoiding triggers of known allergens
  • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever.
  • Revisit clinic 2-4 weeks for follow up and evaluation

References
Varshney, J., & Varshney, H. (2015). Allergic Rhinitis: an Overview. Indian Journal of
Otolaryngology and Head & Neck Surgery, 67(2), 143–149.
https://doi.org/10.1007/s12070-015-0828-5
Wheatley, L. M., & Togias, A. (2015). Allergic Rhinitis. New England Journal of Medicine,
372(5), 456–463. https://doi.org/10.1056/nejmcp1412282
Wise, S. K., Lin, S. Y., Toskala, E., Orlandi, R. R., Akdis, C. A., Alt, J. A., Azar, A., Baroody, F.
M., Bachert, C., Canonica, G. W., Chacko, T., Cingi, C., Ciprandi, G., Corey, J., Cox, L.
S., Creticos, P. S., Custovic, A., Damask, C., DeConde, A., . . . Zacharek, M. (2018).
International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis.
International Forum of Allergy & Rhinology, 8(2), 108–352.
https://doi.org/10.1002/alr.22073

Resting membrane potentials

 

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