HEENT Focused Exam SOAP Note

ID: T.J., 28 year old African American Female

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

HPI: T.J. presents with a chief complaint of a sore and itchy throat, nasal drainage, and itchy
eyes. She states the onset of symptoms is one week ago and has persisted since then. She states
that her throat pain is mild to moderate and worse in the morning upon waking and when
swallowing. Rates throat pain 4/10 and throat itchiness 5/10 on a 0-10 scale. States that she has
been using "throat drops" and increasing her water intake helps to alleviate her sore throat. States
that her nose “runs all day.” Denies cough. Nasal discharge is clear and watery. States that she
has not attempted any treatments for her nasal symptoms, denying the use of over-the-counter
medications. Denies congestion. Additionally, she reports itchy watery eyes which intensifies
when she rubs them. Denies dry eye, eye pain, or use of any medication or eye drops to alleviate
symptoms. Denies any previous history of similar symptoms, seasonal allergies, or recent contact
with sick individuals. Denies fever, chills, and recent illness. Denies a history of seasonal
allergies stating that she has never had problems with allergies to “anything outdoors.” However,
reports that her sister suffers from hay fever and believes this may be allergy related. History of
asthma and allergies to Penicillin, cats, and dust.
Ms. Jones presents with complaints of a sore and itchy throat, nasal drainage, and itchy
eyes. She reports that the symptoms all started one week ago and have been constant since onset.
She states her throat pain is worse upon waking and she has increased soreness with swallowing.
The throat pain is rated as 4/10. To treat her sore throat, she has been using “throat drops” and
“drinking more water”, both of which “help a little bit”. She reports the nasal drainage is clear
and “thin and drippy” and denies attempting to treat her nasal symptoms. She states her eyes are
“itchy around the rims, mostly, and the more I rub them, the itchier they get”, and reports that
“they’ve been watery”. She denies attempts to treat her eye complaints. She denies a history of
similar symptoms, denies a history of seasonal allergies, and denies any recent sick contacts.
However, she does compare her symptoms to the “hay fever” her sister has been experienci

Past Medical History:

Asthma: Diagnosed at the age of 2. Currently manages symptoms with an albuterol
inhaler as needed. Asthma is triggered by exposure to cat dander and dust. The patient
reports that her last asthma-related hospitalization was during high school and never
required intubation. The most recent chest X-ray was conducted at 16 years old.

Type 2 Diabetes Mellitus: Diagnosed at age 24 and is currently uncontrolled. The

patient reports discontinuing medication metformin due to unwanted side effects. Also
reports irregularly monitoring blood glucose levels.

Past Surgical History: No past surgeries.

Family History of disease:

 Mother: Living, age 50. HTN, Dyslipidemia.
Father: Deceased, MVA, age 58. HTN, Dyslipidemia, T2DM.
Sister: Living. Hay Fever, Asthma.
Brother: Living, age 25, no medical history.
Maternal Grandmother: Deceased, Stroke, age 73. HTN, Dyslipidemia.
Maternal Grandfather: Deceased, Heart attack, age 78. HTN, Dyslipidemia.
Paternal Grandmother: Living, age 83. HTN.
Paternal Grandfather: Deceased, Colon cancer, age 65. T2DM.
Paternal Uncle: Alcoholism.

Habits: Single, never married. Lives with mother and sister. No children. Never pregnant.
Currently not sexually active. Social drinker. Reports drinking 2-3 times per month with friends.
Denies substance abuse, illicit drug use, smoking, and vaping. Currently working full time and
obtaining Bachelor’s degree in accounting. Volunteers at church. Reports strong support system
among family and friends.

Medications: Lozenges, name unknown, taken every 1-3 hours

Proventil 90 mcg 2-3 puffs as needed for asthma symptoms.

Allergies: The patient reports an allergy to penicillin, resulting in a systemic rash and hives.
Exposure to cat dander and dust exacerbates asthma symptoms, causing itchy eyes and a runny
nose. Denies allergies to food, pollen, latex, and mold.

Review of Systems:
General: Denies loss of appetite, weight changes, fever, chills, night sweats, or fatigue.
Reports headaches and blurred vision when studying for too long.
HEENT: Reports itchy, sore throat and pain while swallowing. Denies mouth lesions and
tooth pain. Reports itchy eyes, headache, and blurred vision while reading. Denies use of
corrective lenses and contacts. Denies ear discharge, itchiness, pain, hearing loss, or
tinnitus. Endorses nose discharge and denies nasal congestion.
Cardio: Hypertensive. Denies palpitations, chest pain, peripheral edema, claudication,
irregular heartbeats, and murmur.
Resp: History of Asthma. Last hospitalization and chest x-ray at age 16. Denies cough,
wheezing, shortness of breath, dyspnea, orthopnea, and hemoptysis.
GI: Denies nausea, vomiting, diarrhea, abdominal pain, constipation, bloating, or change
in bowel habits.
GU: Denies difficulty with bladder, pain, hematuria, discharge, or dysuria.
Integumentary: Reports acne and dry skin. Acanthosis nigricans noted. Nose is red and
chapped. Eyelids red. Denies nail or breast changes.
Hematologic/Lymphatic: Denies easy bruising or bleeding, anemia, transfusion history,
syncope, and lymphadenopathy.
Allergic/Immunologic: Allergy to penicillin, cats, and dust. Denies recurrent infections.

Objective
Vital Signs: BP 139/87; HR 82; RR 16; SaO2 99% RA;
T 98.9; Wt. 88 kg; Ht. 170 cm; BMI 30.5
 General: Pleasant, calm, cooperative, well nourished, in no distress. Alert and oriented x
4, normal mood and affect. Ambulating without difficulty.
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable masses, normal hair
distribution.
Eyes: Bilateral eyes with equal hair distribution, conjunctiva clear and injected,
anicteric sclerae, EOM intact, PERRLA, normal convergence, no edema or ptosis.
Left fundus has sharp disc margins without exudate or hemorrhage. Right fundus
reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40.
Ears: Equal shape bilaterally. External auditory canals clear without
inflammation. Tympanic membranes are pearly gray, and translucent with
positive light reflex bilaterally. Hearing intact. Weber, Rinne, and Whisper test
normal bilaterally.
Nose: No external lesions, mucosa boggy and pale bilaterally. Septum midline.
No pain with palpation of maxillary and frontal sinuses.
Mouth: Mucous membranes moist, no mucosal lesions or wounds visualized.
Tonsils +1 without inflammation. Uvula midline.
Teeth/Gums: Adequate dental hygiene. No obvious caries or periodontal disease.
No gingival inflammation or significant resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate. Posterior
slightly erythematous with mild cobblestoning and post-nasal discharge.
Neck: No cervical or infraclavicular lymphadenopathy. Thyroid is smooth
without goiter or nodules. Acanthosis nigricans present. Carotid pulses +2
bilaterally, no thrills or buit, no clicks in jaw with full range of motion.
Respiratory: Chest symmetrical rise and fall during respiration. Quiet and unlabored.
Lung sounds clear without wheezes, crackles, or cough.

Assessment: Allergic Rhinitis

Differential Diagnoses: Acute Sinusitis, Upper Respiratory Infection, Pharyngitis

Plan:
o Initiate trial of loratadine (Claritin) 10 mg by mouth daily.
o Encourage the patient to keep a record of when her symptoms occur, how often they
occur, and how severe they are. Remember to bring the log to the next appointment.
o Provide the patient with a referral to an ophthalmologist for a more thorough eye
assessment.
o Educate the patient on avoiding triggers and known allergens to help manage her
symptoms.
o Seek medical attention if symptoms worsen or a severe allergic reaction occurs.
o Follow-up at the clinic in 2-4 weeks for further evaluation and to monitor progress.

Rationale for Findings and Plan:

Allergic rhinitis is characterized by sneezing, an itchy nose, difficulty breathing, and clear runny
nasal discharge (Bousquet et al., 2020; Drazdauskaitė et al., 2021). This condition is caused by
the body's reaction to inhaled allergens, resulting in inflammation of the nasal mucosa due to
type 2 helper T (Th2) cells (Drazdauskaitė et al., 2021). Common allergens causing a histamine
reaction include seasonal pollens, molds, dust mites, and pets. As discovered during the
assessment, people with a family history of allergic rhinitis or asthma are likelier to develop this
condition (Drazdauskaitė et al., 2021). According to the patient, her sister suffers from hay fever
and asthma, while the patient has asthma. In addition to physical symptoms, a nasal exam may
show swollen nasal mucosa and clear discharge. The inferior turbinates may appear pale or blue,
and nasal mucosa may have a cobblestone texture.

However, it is essential to differentiate allergic rhinitis from other possible diagnoses that present
near or the same symptoms (nasal discharge, sore throat, throat pain) such as acute sinusitis,
upper respiratory infection, and pharyngitis (Bousquet et al., 2020). Sinusitis commonly presents
with thick nasal discharge (yellow or green), fever, and pain in the sinus areas. An upper
respiratory infection or common cold often includes systemic symptoms such as fever, body
aches, and fatigue. Pharyngitis is a condition where the throat is sore and inflamed, making it
painful or difficult to swallow, and is caused by either a viral or bacterial infection. To
distinguish it from allergic rhinitis, accompanying systemic symptoms include enlarged tonsils or
visible signs of infection in the throat (Bosquet et al., 2020).

For someone experiencing symptoms like sneezing, itching, or a runny nose due to an allergic
reaction, most patients benefit from pharmacotherapy, which can significantly improve their
quality of life when implemented correctly (Drazdauskaitė et al., 2021). In recent years, there has
been a stronger emphasis on utilizing inhaled nasal steroids as the primary method of treating
upper respiratory allergies, although it is best to start using them three to four weeks prior to the
start of allergy season (Zimlich, 2021). However, second-generation antihistamines such as
loratadine and cetirizine are equally effective for patients that prefer oral administration. Due to
their unparalleled safety and effectiveness, these over-the-counter medications are still
prescribed as primary treatment, because they avoid sedation by not penetrating the blood-brain
barrier (Drazdauskaitė et al., 2021; Zimlich, 2021). Antihistamines block the effects of
histamine, which is released during an allergic reaction. Although individual responses to these
medications may vary, all are equally effective at decreasing allergy symptoms (Bousquet et al.,
2020). In this case, I suggest loratadine 10 mg by mouth daily for T.J. because she reports that
she has to remain alert throughout the day, and it is least likely to cause drowsiness or sedation
(Zimlich, 2021).

Educating T.J. on identifying and avoiding triggers that can exacerbate seasonal allergic rhinitis
is also essential to her care plan. By implementing strategies like trigger avoidance, she can
effectively prevent the worsening of her seasonal allergies (Bousquet et al., 2020). Also, having
the patient keep a running log of her symptoms and when they occur will help the provider
identify potential allergens and triggers and implement interventions to avoid them in the future.

In addition, because of fundus changes during her visual assessment, referral to an

ophthalmologist is vital because of the possibility of progressing diabetic retinopathy (Alyoubi et
al., 2020). Detecting and treating vision problems early can greatly lower the chances of losing
eyesight. Furthermore, T.J. should make a follow-up appointment at the clinic in two to four
weeks for further evaluation and to monitor the progress of the current treatment regimen.
Referral to an allergist may be recommended at the follow-up appointment if relief from allergen
exposure is not subsiding with the implemented interventions.

References

Alyoubi, W. L., Shalash, W. M., & Abulkhair, M. F. (2020). Diabetic retinopathy detection
through deep learning techniques: A review. Informatics in Medicine Unlocked, 20.
https://doi.org/10.1016/j.imu.2020.100377

Bousquet, J., Anto, J. M., Bachert, C., Baiardini, I., Bosnic-Anticevich, S., Canonica, G. W.,
Melén, E., Palomares, O., Scadding, G. K., Togias, A., & Toppila-Salmi, S. (2020). Allergic
rhinitis. Nature Reviews Disease Primers, 6, 95. https://doi.org/10.1038/s41572-020-00227-0

Drazdauskaitė, G., Layhadi, J.A. & Shamji, M.H. (2021). Mechanisms of allergen
immunotherapy in allergic rhinitis. Current Allergy and Asthma Reports, 21, 2.
https://doi.org/10.1007/s11882-020-00977-7

Zimlich, R. (2021). Fall allergies: Medications remain stable, but a lot has changed.
Contemporary Pediatrics, 38(9), 16-17.
https://www.proquest.com/openview/4f0b8ba03cdf834eea455cb1f6594300/1?pq-
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