HEENT Documentation Shadow Health

HEENT Documentation Shadow Health

SOAP Note: Ms. Jones – Allergic Rhinitis

Subjective:Chief ComplaintSore throat, itchy eyes, runny nose for one week.Onset and Nature of SymptomsSymptoms started spontaneously, constant, worse throat pain in the morning. Throat pain rated 4/10, throat itchiness 5/10.Treatment HistoryOccasional throat lozenges used with slight relief.Associated SymptomsSoreness while swallowing, denies cough or recent illness.ExposuresNo exposure to sick individuals.Medical HistoryNo history of seasonal allergies, sister has “hay fever.”

Objective:GeneralMs. Jones, a pleasant, obese 28-year-old African American woman in no acute distress. Alert and oriented.HeadNormocephalic, atraumatic. Scalp with no masses, normal hair distribution.EyesBilateral eyes with equal hair distribution, no lesions, ptosis, or edema. Conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left eye vision: 20/20, right eye vision: 20/40. Fundoscopic exam reveals mild retinopathic changes.EarsEqual ear shape. External canals without inflammation. Tympanic membranes pearly grey and intact bilaterally.NoseSeptum midline, nasal mucosa boggy and pale bilaterally. No pain with sinus palpation.Mouth/ThroatMoist buccal mucosa, no wounds. Adequate dental hygiene. Uvula midline. Tonsils 1+, posterior pharynx slightly erythematous with mild cobblestoning.NeckNo lymphadenopathy. Thyroid smooth without nodules. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit.RespiratorySymmetrical chest, clear lung sounds, no wheezes, crackles, or cough.

Assessment:Allergic Rhinitis

Plan:1. Encourage monitoring symptoms and logging episodes for the next visit.2. Initiate loratadine (Claritin) 10 mg orally daily.3. Encourage increased fluid intake and frequent handwashing.4. Educate on trigger avoidance and known allergens.5. Educate on when to seek care (uncontrollable epistaxis, worsening headache, or fever).6. Follow up in 2-4 weeks for evaluation.

Related Services

i-Human Case Study Answers

i-Human modules help

Shadow Health Assessments Help