NURS 634 SOAP NOTE 2: Allergic Rhinitis, History & Physical Examination.

History & Physical Examination Patient Demographics: Name: J.V. Age/race/sex: 28 Hispanic Male Clinical site: Primary Care clinic SUBJECTIVE DATA Chief Complaints: “My throat is scratchy, I’ve been sneezing non-stop, my nose has been running and congested, my eyes have been watery and itchy and I’ve been coughing for about two days now”. History of Present Illness: Mr. V presents for a sick visit with scratchy throat, sneezing, non-productive cough, rhinorrhea with congestion, and itching, watery eyes for 48 hours. Patient denies any pain, fever, chills, body aches, SOB, n/v, or weight lost. Reports general malaise mostly from OTC cough and cold medicine. States cough is intermittent throughout the day but is worse upon waking. The patient has taken OTC Tylenol cold and allergy for moderate relief for about hours. Patient reports symptoms like this has occurred several times in the past but mostly during the spring and fall months or while cleaning his home or even while at work. During those time he was told his allergies had flared and he was given an OTC medication to use but he can’t remember which one it was. At this visit the patient hopes to receive something that will help subside his symptoms so that he can feel better right now but he also hopes to find something that can help to reduce the number of times he’s getting these allergy flares. Past Medical History: Dust and Mold allergies that causes sneezing and coughing controlled with OTC antihistamine. (can’t remember which one) Seasonal allergies-allergic-type-symptoms such as sneezing, water-itchy eyes, nasal itchiness and discharge, and cough. Eczema controlled with daily lubricants and emollients. Last skin flare was about three months ago. Past Surgical History: No surgeries to date Allergies: NKA to food or medications. Patient does report allergies seasonal allergies and allergies to dust and mold which causes allergic-type-symptoms listed in PMH. Medications: Tylenol cold with allergy relief 30mls every 8 hours as needed for symptom relief. Health Maintenance: Patient receives annual flu shots. Last flu shot was given September 29th at CVS. All other immunizations are up-to-date including TDaP, MMR, and Varicella. Personal & Social History: Lives in a single family home with his wife and young daughter, whose five years old. He owns a lawn care business and works about 6-7 days a week, he has a dependable car and truck and is happy with his occupation. Denies any smoking or illicit drug abuse. Patient reports he is a casual drinker and may have a shot or two at the bar on Fridays with his friends. Patient usually goes to the gym 3 days/week to do cardio and strength training. However, he states he gets lots of exercise as well on his job. Patient is sexually active with only one sex partner, his wife. 24 hour diet recall: B- Banana, one piece of toast with peanut butter, and a cup of milk; L-Steak Burrito with chips and salsa with a coconut water; Snack-one beef jerky and a cherry Jarrito; D-KFC (2 piece dark chicken thighs with corn on the cob, a biscuit, and a Mountain Dew)