A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
Chief complaint: Persistent “runny nose” for 3-week duration, associated clearing of throat, and nasal congestion on awakening in the morning.
Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20. WT: 205 BMI:____ (you choose what to fill in)
What further ROS questions will you want to ask her? List at least three.
What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? Describe at least three (one of them should be the primary dx).
What laboratory tests will help you rule out some of the differential diagnoses?
You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR). Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient?
List at least two treatment options: medications with dose, side effects and/or cautions in the older adult. Write your order in the SOAP note as you would for an actual patient.
What education will you provide for this patient and family?
When will you have the patient follow-up? Be specific.
Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note.
Support your soap note and research with 5 APA references.
