(Student Name)Miami Regional UniversityDate of EncounterP

(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C,
FNP-C
Soap Note #1 DX: Allergic Rhinitis
PATIENT INFORMATION
Name: Ms. JD
Age: 23-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: NKDA
Current Medications:
· Cetirizine 10mg/d
· Mucinex-D
PMH:
Immunizations: Tetanus.
Preventive Care: No history.
Surgical History: No history of surgery.
Family History: Father- alive, 60 years old, healthy.
Mother-alive, 54 years old, HTN,
hyperlipidemia.
Sister-alive, 20 years old, Asthma.
Social History: Denies alcohol, tobacco or illicit drugs use.
College student, lives alone in campus hostels. Physically active
and occasionally does exercise.
Sexual Orientation: Active
Nutrition History: Eats balance diet but avoids excessive junk
food.

Subjective Data:
Chief Complaint: “stuffy nose” that has lasted for two weeks.
Symptom analysis/HPI:
Ms. JD is a 23-year-old patient who presents with complaints of
a stuffy nose, rhinorrhea, congestion and sneezing. She reports
a spontaneous start of the symptoms that have remained
consistent. Indicates no particular aggravating symptoms but
reports higher severity of the symptoms in the morning. She
complains of a sore throat and itchy eyes. She reports an all -day
clear runny nose. She indicates consistent outdoor handball
practice routine. She reports using Cetirizine and Mucinex-D
which do not help. She denies vision or taste changes. She
denies fever or chills. Denies diagnosis with allergies.
Review of Systems (ROS)
CONSTITUTIONAL: Denies change in weight, fatigue, fever,
night sweats or chills. NEUROLOGIC: Denies seizure,
numbness or blackout.
HEENT: HEAD: Denies headache. Eyes: Reports itchy eyes.
Denies vision change. Ear: Denies hearing loss, pain or
discharge. Nose: Admits stuffiness, nasal congestion and clear
discharge. Denies nose bleeds. THROAT: Reports a sore throat.
RESPIRATORY: Patient denies breathing difficulties, cough,
wheezing, TB, pneumonia.
CARDIOVASCULAR: No palpitations or chest pain. No edema,
PND or orthopnea.
GASTROINTESTINAL: Denies nausea, abdominal pains,
vomiting and diarrhea. Denies ulcers hx.
GENITOURINARY: Denies change in urine color, urgency and
frequency. Regular menses cycle. Denies ovulation pain. Denies
hematuria and dysuria.
MUSCULOSKELETAL: Denies back and joint pains or
stiffness.
SKIN: No skin rashes or lesions.
Objective Data:
VITAL SIGNS: Temperature: 36.7 °C, Pulse: 78, BP: 119/87

mmHg, RR 20, PO2-97% on room air, Ht- 1.60m, Wt 67kg, BMI
26.
GENERAL APPREARANCE: Healthy appearing. Alert and
oriented x 3. No acute distress. Well-groomed and responds
appropriately.
NEUROLOGIC: Alert, oriented, posture erect, clear speech.
gait. to person, place, and time.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-
tender. Maxillary sinuses mild tenderness. Eyes: Bilateral
conjunctival injection, no icterus, visual acuity and extraocular
eye movements intact. No edema, no lesions, no haemorhage.
Clear discharge. Ears: Bilateral canals patent without erythema,
edema, or exudate. Bilateral tympanic membranes intact, pearly
gray with sharp cone of light. Nose: Mild erythema of nasal
mucosa which is paly and boggy, congested nares with
rhinorrhea. No nasal crease. Throat: Posterior pharynx with no
tonsillar edema, erythema or exudate. Uvula midline. Moist
mucous membranes.
Neck: supple. No cervical or post auricular lymphadenopathy.
No thyroid swelling or masses. Non tender
CARDIOVASCULAR: S1and S2. RRR w/o sound. Capillary
refill in 2 sec. Pulse >3.
RESPIRATORY: Regular respiration. Thorax symmetrical. No
increased respiratory effort. Breath sounds vesicular on
auscultation.
GASTROINTESTINAL: No hepatosplenomegaly. Bowel sounds
present in all four quadrants. no bruits over renal and aorta
arteries. Soft, non-distended, non-tender abdomen with no
palpation.
MUSKULOSKELETAL: Full motion range in all extremities.
INTEGUMENTARY: intact, no lesions or rashes.
ASSESSMENT:
Main Diagnosis

Allergic Rhinitis (ICD-10 code J30.8)
Allergic rhinitis is an inflammatory infection of the nasal
mucosa characterized by nasal congestion, sneezing and
rhinorrhea (Greiner et al., 2011). It is an inflammation of the
interior nasal lining due to inhalation of an allergen that results
in a runny nose, stuffy nose, itchy eyes and sore throat
(Seidman et al., 2015).
Differential diagnosis:
· Viral Rhino Sinusitis
Characterized by headaches, sore throat, nasal congestion, fever
and sneezing (Reintjes & Peterson, 2016). Patient denied
headache or fever.
· Acute Conjunctivitis
Associated with red eye and mucopurulent discharge and at
times lack of itching (Azari & Barney, 2013). Patient reported
itchy eyes but with a clear discharge.
PLAN:
Labs and Diagnostic Test to be ordered:
· Skin prick testing
· Serum Immunoassay test
· Acoustic rhinometry
Pharmacological treatment:
· Fexofenadine 120mg daily oral dose (Bernstein, Schwartz &
Bernstein, 2016).
· Fluticasone furoate 2 sprays (27.5 µg/spray) EN, once daily
Non-Pharmacologic treatment:
· Allergen avoidance.
· Allergen immunotherapy
Education
· Patient should be educated on the nature of the disease,
probability of progression and the importance of treatment
(Greiner et al., 2011).
· Education on safety concern of the medications.

· Information on potential side effects of the medications to
reduce higher treatment expectations.
· Educate the patient on efficient nasal drug admission for
effective drug compliance and treatment.
· Education on the aims of the treatment and possible benefits to
enhance adherence to the medication.
Follow-ups/Referrals
· Follow up appointment after weeks to monitor the efficacy of
administered medication and subsequent interventions.
· No referrals needed at this time.
References
Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: a
systematic review of diagnosis and treatment. Jama, 310(16),
1721-1730.
Bernstein, D. I., Schwartz, G., & Bernstein, J. A. (2016).
Allergic rhinitis: mechanisms and treatment. Immunology and
Allergy Clinics, 36(2), 261-278.
Greiner, A. N., Hellings, P. W., Rotiroti, G., & Scadding, G. K.
(2011). Allergic rhinitis. The Lancet, 378(9809), 2112-2122.
Reintjes, S., & Peterson, S. (2016). Rhino sinusitis. Oxford
Medicine Online
Seidman, M. D., Gurgel, R. K., Lin, S. Y., Schwartz, S. R.,
Baroody, F. M., Bonner, J. R., ... & Nnacheta, L. C. (2015).
Clinical practice guideline: allergic rhinitis. Otolaryngology–
Head and Neck Surgery, 152(1_suppl), S1-S43.

Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for,
and what our margin remarks might be about on your write ups
of patients. Since at all of the white-ups that you hand in are
uniform, this represents what MUST be included in every write-
up.
1) Identifying Data (___5pts): The opening list of the note. It
contains age, sex, race, marital status, etc. The patient
complaint should be given in quotes. If the patient has more
than one complaint, each complaint should be listed separately
(1, 2, etc.) and each addressed in the subjective and under the
appropriate number.
2) Subjective Data (___30pts.): This is the historical part of the
note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or
severity, timing, setting, factors that make it better or worse,
and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all
pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related
to the complaint/problem (10pts). If more than one chief
complaint, each should be written u in this manner.
3) Objective Data(__25pt.): Vital signs need to be present.
Height and Weight should be included where appropriate.
a) Appropriate systems are examined, listed in the note and
consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for
each relevant system.
c) Any abnormalities must be fully described. Measure and
record sizes of things (likes moles, scars). Avoid using “ok”,
“clear”, “within normal limits”, positive/ negative, and
normal/abnormal to describe things. (5pts).
4) Assessment (___10pts.): Diagnoses should be clearly listed
and worded appropriately.
5) Plan (___15pts.): Be sure to include any teaching, health
maintenance and counseling along with the pharmacological and
non-pharmacological measures. If you have more than one
diagnosis, it is helpful to have this section divided into separate
numbered sections.
6) Subjective/ Objective, Assessment and Management and
Consistent (___10pts.): Does the note support the appropriate
differential diagnosis process? Is there evidence that you know
what systems and what symptoms go with which complaints?
The assessment/diagnoses should be consistent with the
subjective section and then the assessment and plan. The
management should be consistent with the assessment/
diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and
complete?
Comments:
Total Score: ____________
Instructor: __________________________________

Guidelines for Focused SOAP Notes
· Label each section of the SOAP note (each body part and
system).
· Do not use unnecessary words or complete sentences.
· Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells
you).
Chief Complaint (CC): a statement describing the patient’s
symptoms, problems, condition, diagnosis, physician-
recommended return(s) for this patient visit. The patient’s own
words should be in quotes.
History of present illness (HPI): a chronological description of
the development of the patient's chief complaint from the first
symptom or from the previous encounter to the present. Include
the eight variables (Onset, Location, Duration, Characteristics,
Aggravating Factors, Relieving Factors, Treatment, Severity-
OLDCARTS), or an update on health status since the last
patient encounter.
Past Medical History (PMH): Update current medications,
allergies, prior illnesses and injuries, operations and
hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information
about the patient's family (parents, siblings, and children).
Include specific diseases related to problems identified in CC,
HPI or ROS.
Social History(SH): An age-appropriate review of significant
activities that may include information such as marital status,
living arrangements, occupation, history of use of drugs,
alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review.
List positive findings and pertinent negatives in systems
directly related to the systems identified in the CC and
symptoms which have occurred since last visit; (1)
constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3)

ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory,
(6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-
}.integument (skin and/or breast), (10) neurological, (11)
psychiatric, (12) endocrine, (13) hematological/lymphatic, {14)
allergic/immunologic. The ROS should mirror the PE findings
section.
0: OBJECTIVE DATA (information you observe, assessment
findings, lab results).
Sufficient physical exam should be performed to evaluate areas
suggested by the history and patient's progress since last visit.
Document specific abnormal and relevant negative findings.
Abnormal or unexpected findings should be described. You
should include only the information which was provided in the
case study, do not include additional data.
Record observations for the following systems if applicable to
this patient encounter (there are 12 possible systems for
examination): Constitutional (e.g. vita! signs, general
appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory,
GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The
focused PE should only include systems for which you have
been given data.
NOTE: Cardiovascular and Respiratory systems should be
assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered
during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the
appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have
identified. These diagnoses are the conclusions you have drawn
from the subjective and objective data.
Remember:Your subjective and objective data should support
your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be "ruled out" rather state the
working definitions of each differential or primary diagnosis

(es).
For each diagnoses provide a cited rationale for choosing this
diagnosis. This rationale includes a one sentence cited
definition of the diagnosis (es) the pathophysiology, the
common signs and symptoms, the patients presenting signs and
symptoms and the focused PE findings and tests results that
support the dx. Include the interpretation of all lab data given in
the case study and explain how those results support your
chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient).
Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing
information and provide EBP to support ordering each
medication. Be sure to include both prescription and OTC
medications.
2. Additional diagnostic tests include EBP citations to support
ordering additional tests
3. Education this is part of the chart and should be brief, this is
not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or
circumstances of return. You must provide a reference for your
decision on when to follow up.
<table border="0" width="100%" cellpadding="0"
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<td bgcolor="#000000" style="padding-left:2px; padding-
right:10px; padding-top:2px; padding-bottom:2px">

Miami
Regional University   (Acct
#3111)</td>
</tr>
</table>


<table border="0" width="100%" cellpadding="0"
cellspacing="0" bgcolor="#C0C0C0">
<tr>
<td width="50%">  Case ID #:
2844-20220315-004
  (Status: Approved)
</td>
<td width="50%">

Date of Service:
3/15/2022 </td>
</tr>
</table>
<table border="0" cellspacing="0" WIDTH="100%"
bordercolor="#99CCFF">
<tr>
<td WIDTH="100%" bgcolor="#000000" colspan="2"
style="border-style: solid; border-width: 2px">
Student Information - Santiesteban Molina,
Osmel</td>
</tr>
<tr>
<td WIDTH="50%" bgcolor="#FFFFFF" align="right">
Semester:</td>
<td WIDTH="50%" bgcolor="#FFFFFF">

Spring

</td>
</tr>
<tr>
Course:</td>

MSN6150C Advanced Practice Pediatrics

</td>
</tr>
<tr>
Preceptor: </td>

REYES-CHOUZA, CARLOS

</td>
</tr>
<tr>
<td WIDTH="50%" bgcolor="#FFFFFF" align="right"
height="18" valign="top">
Clinical Site:</td>
<td WIDTH="50%" bgcolor="#FFFFFF" height="18">

IDEAL MEDICAL CENTER

</td>
</tr>
<tr>
height="18" valign="top">

Setting Type<font

Underserved area/population

</td>
</tr>
<tr>
<td WIDTH="100%" bgcolor="#000000" align="right"
colspan="2" style="border-style: solid; border-width: 2px">
size="2">Patient Demographics</td>
</tr>
<tr>
<td bgcolor="#FFFFFF">

Age:</td>

8 years

</td>
</tr>
<tr>
Race
White, Non Hispanic
</td>
</tr>
<tr>
size="2">Gender<font

<td WIDTH="50%" bgcolor="#FFFFFF">
Male
</td>
</tr>
<tr>
size="2">Insurance
Medicaid
</td>
</tr>
<tr>

size="2">Referral
No referral
</td>
</tr>
<tr>
<td valign="top" bgcolor="#000000" colspan="2"
size="2">Clinical Information</td>
</tr>
<tr>
<td bgcolor="#FFFFFF" align="right">
Time with Patient:</td>

15 minutes</td>
</tr>
<tr>
Consult with Preceptor:</td>

5 minutes</td>
</tr>
<tr>
Type of Decision-
Making:</td>

Straightforward

</td>
</tr>
<tr>
Reason for Visit:</td>

Episodic
</td>
</tr>
<tr>

Chief Complaint:</td>
Per mother:"My son looks pale and is

always tired"
</td>
</tr>
<tr>
Type of HP:</td>

Problem Focused
</td>
</tr>
<tr>
<td bgcolor="#FFFFFF" align="right" valign="top">
Social Problems
Addressed:</td>

Income/Economic Sanitation/Hygiene Safety I
nterpersonal Relationships Emotional Growth &
Development Nutrition/Exercise 
 </td>
</tr>
</table>
<TABLE BORDER="0" CELLPADDING="0"
CELLSPACING="0" WIDTH="100%"
<tr>
<td width="100%" bgcolor="#000000" align="center"
Procedures/Skills
(Observed/Assisted/Performed)</td>
</tr>
<tr>
<td width="100%" bgcolor="#FFFFFF" align="left"
colspan="2">

Physical Assessment - Physical Assessment (Perf) 
</td>
</tr>
</table>
<tr>
<td width="100%" bgcolor="#000000" align="center"
ICD-10
Diagnosis Codes</td>
</tr>
<tr>
<td width="10%" bgcolor="#FFFFFF" align="right"
valign="top">
#1 -<font

size="2"> 

</td>
<td width="90%" bgcolor="#FFFFFF" align="left">

D50.9 - IRON DEFICIENCY ANEMIA, UNSPECIFIED

</td>
</tr>
<tr>
<td WIDTH="100%" align="right" bgcolor="#000000"
CPT
Billing Codes</td>
</tr>
<tr>
<td width="10%" bgcolor="#FFFFFF" align="right"
valign="top">

#1 - 

</td>
<td width="90%" bgcolor="#FFFFFF" align="left">

99212 - OFFICE/OP VISIT, EST PT, MEDICALLY
APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 10-
19 MIN

</td>
</tr>
</table>
cellpadding="1">
<tr>
colspan="2" style="border-style: solid; border-width: 2px"

Birth & Delivery</td>
</tr>
</table>
cellpadding="1">
<tr>
colspan="2" style="border-style: solid; border-width: 2px"
Medications</td>
</tr>
<tr>
<td width="50%" bgcolor="#FFFFFF" align="right">
# OTC Drugs taken
regularly:</td>

valign="top">

2</td>
</tr>
<tr>
# Prescriptions currently
prescribed:</td>
valign="top">

2</td>
</tr>
<tr>
# New/Refilled Prescriptions This
Visit:</td>

valign="top">

1</td>
</tr>
<tr>
valign="top">

Types of New/Refilled Prescriptions This
Visit: 
Hematology/Oncology - Miscellaneous
hematology/oncology 
 </td>
valign="top">

Adherence Issues with
Medications: 
 </td>
</tr>
</table>
CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF">
<tr>
colspan="2" bordercolor="#99CCFF" style="border-style: solid;
border-width: 2px">
Other
Questions About This Case</td>
</tr>

<tr>
height="18">
Patient's Primary
Language:</td>

English

</td>
</tr>
<tr>
height="18">
Smoking Assessment:</td>

Never

</td>
</tr>
<tr>
height="18">
Advanced Directive:</td>

No

</td>
</tr>
<tr><td bgcolor='#FFFFFF' valign = 'top' width='50%'>Packs per
day:</td><td bgcolor='#FFFFFF'>0</td></tr>
</table>

CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF">
<tr>
<td width="100%" bgcolor="#000000" align="left"
valign="top" colspan="2" bordercolor="#99CCFF"
size="2">Clinical Notes</td>
</tr>
<tr>
valign="top" colspan="2">


</td>
</tr>

(Student Name)Miami Regional UniversityDate of EncounterP

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