SOAP Note Allergies PDF

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SOAP Note Allergies...

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A 31-year-old white male comes in for an evaluation of his allergic rhinitis. He is known to your practice for the last decade. Presently he is on Flonase nasal spray and Zyrtec daily for his allergic rhinitis. He owns his own business ‘Dr. Vinyl’ where he specializes in repair of vinyl in automobiles, boats, recreational vehicles, etc. Exposure to the smell of several of the products he works with has resulted in dissatisfactory management of his typical allergic rhinitis. On numerous occasions over the last decade he has requested and been given an ‘allergy shot’. A review of his medical record reveals to you this ‘shot’ has been a steroid injection. BP 122/74, P 76, R 18

Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion. Subjective (S): The Patient is a 31-year-old white male that has come in for an evaluation of his allergic rhinitis. He has been a patient for ten years. He is currently using Flonase nasal spray and taking Zyrtec daily for allergic rhinitis. He owns a vinyl business and is continuously exposed to the chemicals in the vinyl that has led to dissatisfaction with the management of his allergic rhinitis. Several times over the last decade, he has been administered an “allergy shot.” According to our records, this shot that was administered was a steroid injection. Objective (O): BP 122/74, P 76, R 18 Assessment (A): During my assessment, the patient is noted to have redness of the tissue lining the eyelids, and intensification of nasal mucus production. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Other signs of allergic rhinitis are crankiness, exhaustion, and a decreased appetite. (Arcangelo et al., 2017). Once mediators are released into the mucus membranes of the nasal passages, the mediators initiate a widening of the blood vessels, trigger capillary penetrability, amplified mucus making, and stimulus of the nerve ends. (Arcangelo et al., 2017). The following signs are copious nasal secretion, nasal obstruction, and nasal itching. (Arcangelo et al., 2017). The most acute signs involve violent periods of sneezing and a complete nasal obstruction of airflow through the nose due to large amounts of nasal secretions. (Arcangelo et al., 2017). Plan: To determine a diagnosis of allergic rhinitis, it would begin with a complete patient and family history of definitive indicators and the occasions, locations, and environments where they happen. (Hayden and Womak, 2007). If further diagnosis is needed, the skin-prick test is specific for inhaled allergens, and it is an affordable, simple test that is performed at an

allergists’ office. (Hayden and Womak, 2007). The radioallergosorbent testing (RAST) allows las detection of serum IgE antibodies to allergic triggers. (Arcangelo et al., 2017). The RAST is more definitive and more expensive; the skin testing is more affordable, extra sensitive, and easier to administer. (Arcangelo et al., 2017). Another test is the Wright color test to identify eosinophils in nasal excretions. (Hayden and Womak, 2007). The primary step to manage allergic rhinitis is to find the cause of the allergic reaction. (Hayden and Womak, 2007). Once the allergen has been detected, the patient should try to avoid the trigger as much as possible. (Hayden and Womak, 2007). Therapeutics: The first line of treatment for allergic rhinitis is oral antihistamines for mild to medium allergic reactions. (Hayden and Womak, 2007). To manage allergies, the patient can take antihistamines, adenoidal decongestants, and adenoidal steroids. (Arcangelo et al., 2017). “The first-generation antihistamines, such as diphenhydramine, chlorpheniramine, and brompheniramine, are the older antihistamines.” (Arcangelo et al., 2017, p. 833). These medications are useful for the treatment of allergic rhinitis. (Arcangelo et al., 2017). Still, they have some unpleasant side effects due to their capability to cross the blood-brain blockade and influence the central nervous system. (Hayden and Womak, 2007). This can lead to specific side effects, dry oral mucosa, rapid heart rate, the holding of urine, and gastrointestinal troubles. (Hayden and Womak, 2007). A second line medication for allergic rhinitis is intranasal corticosteroids. (Hayden and Womak, 2007). ”Azelastine (Astelin) and olopatadine (Patanase) intranasal antihistamines are also available to treat allergic rhinitis.” (Arcangelo et al., 2017, p. 833). Intranasal decongestants are a vasoconstrictor that helps to shrink inflamed nasal tissues. (Arcangelo et al., 2017). The mutual use of montelukast and cetirizine is more effective than just cetirizine singlehandedly. (Hayden and Womak, 2007). Third line therapy is the use of intranasal cromolyn and is practical and hardly any side effects.

(Arcangelo et al., 2017). Educational: Patient teaching is crucial in the avoidance of triggers and controlling allergic indicators. (Arcangelo et al., 2017). The patient needs to be educated about the sources of triggers, how the allergen starts signs of an attack, the drugs obtainable and when to treat at home or pursue medical intervention, and how to determine if the therapy is effective. (Arcangelo et al., 2017). References: Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (20161108). Pharmacotherapeutics for Advanced Practice, 4th Edition [VitalSource Bookshelf version]. Retrieved from vbk://9781496374066 Hayden, M. L., & Womack, C. R. (2007). Caring for patients with allergic rhinitis. Journal of the American Academy of Nurse Practitioners, 19(6), 290-8. Retrieved from https://prxherzing.lirn.net/login?url=https://search.proquest.com/docview/212889810? accountid=167104...