NSG6435 Week 3 SOAP ALLERGIC RHINITIS PEDIATRIC

Student Name: Christine Baijnath

Course: NSG6435

Patient Name: 

Date: 

Time: 

Ethnicity: 

Age: 17 Years

Sex: M

SUBJECTIVE (must complete this section)

CC: “Patient presents to the hospital with runny nose that feels very itchy and won’t stop.”

HPI: The patient is a 17 year old boy that presents to the hospital with a chief complaint of a runny and itchy nose that as continued for six days. The runny nose is also accompanied with a head ache and sore throat. The patient reports that he has been experience the severe levels of headache for over a period of 5 years especially on the side of his head and right behind his eyes. According to the parent, the patient began to have the first onset of the pain five days ago after he came home from school with a fleet of runny itchy nose and sneezes. The patient’s pain was releaved with painkillers (Ibuprofen) for the best part of the night, however, when the patient woke up he had a serious purulent drainage through the nasal passages. The parent reported that the drainage subsides by itself especially when the patient has taken plenty of water and breakfast, it appears within a matter of hours. The parent also reported that the runny noses is often aggravated by any form of coldness and dust. He reports that the he also feels slight pain that is above cheekbones and has been using an over the counter Tylenol that provides the patient some relief to the paint (Hu & Li, 2012). At times the patient reports that he experienced mid pain behind the eyes with straining his sight and when he is trying to roll her eyes sideways. The runny nose is also painful and intense during the nights and the mornings. The patient has also experience increased levels of nausea which happens during the day. He denies vomiting. In the past 2 days the patient also experience very bad sore throat that was accompanied by a strong fever. Patient denies abdominal pain, joint pain, pain above cheekbones and coughing. The mild pain is also subsided by using over the counter Tylenol. 

Medications: Patient parent reports that he has been taking over the counter pseudoephedrine nasal decongestant in form of tablets by mouth 2 days. Patient also reports taking oral Tylenol 6 tablets a day in the past 3 days. 

Previous Medical History: None reported, per parent

Developmental History: Patient is developmentally appropriate for age range in all areas (Gross motor, fine motor, self-help, problem solving, social, receptive/expressive language)

Allergies: None reported, per parent

Medication Intolerances: None reported, per parent

Chronic Illnesses/Major traumas: None reported, per parent

Immunizations: Patient is up to date on all vaccines, per parent and immunization record (Varicella, DTaP, Influenza, MMR, Polio)

Hospitalizations/Surgeries: None reported, per parent

Health Promotion/Health Maintenance: Routine Pediatrician visits maintained, per parent

Nutrition/Diet: Patient eats a well-balanced diet, per parent

Exercise/Regimen: Patient is active daily, plays with friends outside, rides bike, swims, and plays soccer 3x/week on a minor league team, per parent.

Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: Mother denies any exposure/use.

Safety Measures: Patient maintains safety precautions by sitting in the back seat of car; in a booster seat and wears a seatbelt. She wears shin guard, cleats, and a chest protector when playing soccer. When bike riding, she wears a helmet and knee pads, and she is accompanied by an adult when swimming and uses floaters.

Screening exams: Routine wellness exam; as recommended by PCP, dental exam twice a year, annual eye exam.

FAMILY HISTORY (must complete this section)

M: 38 y/o, living (Denies any health conditions)

MGM: 61 y/o, living (Hypertension)

MGF: 63 y/o, living (None known health conditions)

 F: 40 y/o, living (None known health conditions)

 PGM: 65 y/o, (Deceased)

PGF: 62 y/o, (Deceased)

Social History: __ lives with her mother, father, and grandmother in Florida and he has no siblings. He is currently ___ student and states that she likes school, has a lot of friends that she loves to play with, and has good grades. He also states she likes playing soccer, riding bikes with her friend who lives next door, and swimming when mommy can watch him.

REVIEW OF SYSTEMS (must complete this section)

General: 

Mother reports fever, mild fatigue, and decreased appetite. Denies any weight changes, chills, or night sweats, per parent.

Cardiovascular: 

No current/recent chest pains, palpations, discomfort, cyanosis, or shortness of breath. 

Skin: 

No delayed healing, rashes, lesions, bleeding, or skin discoloration.

Respiratory: 

No chronic cough, wheezing, hemoptysis, or dyspnea. No history of pneumonia or tuberculosis.

Eyes: 

No visual disturbances, use of eyeglasses, or eye pain. Last eye exam was 5 months ago, 20/20 vision, per parent.

Gastrointestinal: 

Reports lower abdominal pain and diarrhea. Denies nausea, vomiting, constipation, bleeding, or tarry stool. Denies hepatitis, per parent.

Ears: 

 No ear pain, hearing loss, ringing in ears, or discharge.

Genitourinary/Gynecological: 

No urinary frequency, urgency, dysuria, change in color/pain, or rash.

Nose/Mouth/Throat: 

No chronic sinus problems, dysphagia, or hoarseness. No history of frequent nosebleeds, discharge, or oral lesions. Denies any throat pain, congestion, runny nose, sore throat, or pain.

Musculoskeletal: 

No joint pain, stiffness, or limitations in range of motion. Denies any fractures or significant trauma.

Breast: 

No breast lumps, bumps, nipple discharge, or changes noted.

Neurological: 

Denies headaches, seizures, weakness, fainting, or sensory changes. No history of significant paresthesia or blackouts. 

Heme/Lymph/Endo: 

No significant abnormalities or clinical indicators suggestive of hematological, lymphatic, or endocrine disorders noted. Denies night sweats, swollen glands, or significant changes in thirst. No history of blood transfusions or bruising, per parent.

Psychiatric: 

 Denies mood disturbances, nightmares, anxiety, depression, or insomnia.

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight: 

  121 lbs

( kg)

Height: 

 6 cm 

 5( in)

BMI:

146 

BP: 

127/82

Temp: 

 °F / °C

97.5

Pulse: 

69bpm

Resp:  

SPO2: 18 bpm

General Appearance:  The patient appears alert and oriented x3, he is well groomed, well nourished, appropriate affect and is in no acute distress (NAD). The patient is also confident, responds appropriately to questions and interview. 

Skin: His skin is dry and warm, the skin has no lesions and no rashes, and the lungs are CTA bilaterary 

HEENT: 

Headache (Normal)

Eyes:  Negative for redness, positive for itching, tearing and negative for discharge

Ears: ( Normal)

Nose: positive for itching, postnatal drip, positive for congestion and rhinorrhea. 

Throat: Normal

Cardiovascular: There are femoral pulses 2+, RRR having S1 and S2, no gallops, murmurs, or rubs. 

Respiratory: there is no presence of adventitious breath noises and bilateral breath sounds (BBS) to auscultations. 

Gastrointestinal: patient has no abdominal pain, vomiting, nausea, constipation, or diarrhea. The patient also reports having daily bowel movements. 

Breast: (not detected)

Genitourinary: No dysuria or hematuria. 

Musculoskeletal:  ( No pain, stiffness or swelling)

Neurological:  The patient is alert, oriented, and timely. The is intactness in sensation and strength grossly in all extremities. Patient is stable, and with normal gait. 

Psychiatric: the patient is cooperative, seems a bit with anxiety, and denies history of depression. 

Diagnostic Studies: None 

Special Tests: None 

DIAGNOSIS (Minimum required differential and presumptive dx's, can do more)

Differential Diagnoses

1. Allergic Rhinitis
2. Acute Sinusitis
3. Influenza-like illness 

Diagnosis:

Allergic rhinitis

Plan/Therapeutics: 

Labs: Examine the patient’s nasal secretion to determine infectious infections and allergies. Ensure that there is a repeat of labs, conduct X-ray and tests for K+, Ex, BUN, Cr & Gluc

Pharmacologic- For allergies administer dosages for allergy antihistamine (Cromolyn, Beclomethasone or triamcinolone) + and cough suppressants in addition to oral decongestion tablets. It is important to consider injection over tabs for antihistamines (Ma, 2022). Also apply fluticasone nose spray allergy symptoms when they are notice. 

For the runny nose administer cough suppressants and decongestants which should be taken by mouth following the right prescription (Malizia et al., 2021). The patient should also be treated with Amoxyllin 500 mg per day X 3 and a decongestant which should be taken the whole week. It is important to also make a follow up and check if the symptoms continue to persist. For the sore throat, mild antibiotics should be given to the patient.

Diagnostics: Based on the assessment done to the patient condition and the response that were given to the various modes of treatment plan, it is definite that the patient has allergic rhinitis (Malizia et al., 2021). The condition is caused by inflammation of the nasal membranes characterized by nasal congestion, sneezing, rhinorrhea, or the combination of any of the conditions, even though the condition is not life threatening, morbidity related to the condition is also significant. It can however, be fatal if accompanied by severe anaphylaxis or asthma (Theisler, 2022). When the patient comes in contact with an allergens such as pollen, dust mites, animal fur, paint, mold or cat saliva it will release histamine, which is a natural chemical that defends to body from the allergen (Moore, n.d.). This chemical will also cause allergic rhinitis with symptoms such as sneezing, runny nose and itchy nose or eyes. These allergens may also attack the patient in certain times of the year, and pollen which can be problematic. Also grasses and weeds produce more pollen in the summer and in the fall. 

Education Provided:   It is important for the patient to be provide with supportive treatment like taking plenty of fluids and ensuring that he has a good rest (Malizia et al., 2021). The patient should be educated on preventive measures for runny nose in pediatrics, ensure that she has frequent hand wash so as to cleanse germs which  may cause cold flue, also avoid eye, nose and mouth touch (Moore, n.d.). The patient is also advised to avoid allergens where possible. Referrals and consultations should also be provided with contact information in the event that there are any issues that could arise from worsening of the condition or if the patient has a negative reaction on medication, this could be intolerance or allergy (Theisler, 2022). Ensure that follow up is done after three days to assess the process of the medication prescribed to the patient on the condition.

References

Hu, K., & Li, W. (2012). Phototherapy for the treatment of allergic rhinitis. Allergic Rhinitis. https://doi.org/10.5772/19074

Ma, J. (2022). Allergic rhinitis. Pediatric Care Online. https://doi.org/10.1542/aap.ppcqr.396129

Malizia, V., Ferrante, G., Cilluffo, G., Fasola, S., Montalbano, L., & La Grutta, S. (2021). Rhinomanometry: Point of care test (POCT) for allergic rhinitis in children? Allergologia et Immunopathologia, 49(5), 28-31. https://doi.org/10.15586/aei.v49i5.429

Moore, K. (n.d.). Allergic rhinitis: Symptoms, treatment, and home remedies. Healthline. https://www.healthline.com/health/allergic-rhinitis#diagnosis

Theisler, C. (2022). Hay fever/Allergic rhinitis. Adjuvant Medical Care, 152-153. https://doi.org/10.1201/b22898-167