SOAP NOTE – Allergic Rhinitis

“Persistent sneezing, runny nose, and itchy eyes—especially worse when I’m around my cat.”

Sarah Thompson is a 29-year-old female who presents with complaints of persistent nasal congestion, clear rhinorrhea, sneezing, and bilateral eye irritation over the past six months. Symptoms are most prominent when she is at home or in enclosed spaces with her pet cat, a three-year-old domestic shorthair. She reports that her symptoms worsen, particularly in the mornings and evenings. She denies fever, chills, or recent illness. Antihistamines like loratadine have provided partial relief, but symptoms persist daily. She denies sinus pain or facial pressure. No recent travel, changes in environment, or new medications. She has not experienced similar symptoms in the past until adopting the cat last year.

§  Loratadine 10 mg daily (for allergy relief)

§  Multivitamin once daily (general health)

Allergies:

§  Pet dander (cats), pollen (seasonal)

§  No known drug allergies

Medication Intolerances:

§  None reported

Chronic Illnesses/Major traumas

§  Seasonal allergic rhinitis since adolescence

Hospitalizations/Surgeries

§  No history of diabetes, HTN, PUD, asthma, lung disease, heart disease, cancer, TB, thyroid, kidney disease, or psychiatric diagnosis.

Mother with asthma and seasonal allergies. Father with hypertension. No family history of cancer, TB, diabetes, or kidney disease.

She is a college graduate and works as a marketing coordinator. Lives alone in an apartment with her pet cat. Never married. Denies tobacco, alcohol, or recreational drug use. Feels safe at home and work.

No fever, weight change, or chills. Mild fatigue attributed to poor sleep from nasal congestion.

Denies chest pain, palpitations, PND, or edema.

No rashes, bruising, or discoloration.

Intermittent nasal congestion and postnasal drip. No cough, hemoptysis, or dyspnea.

Itchy, watery eyes, especially after pet exposure. No visual disturbances.

Denies abdominal pain, N/V/D, or GI bleeding.

Denies ear pain or hearing changes.

No urinary symptoms. Sexually active with one partner. Denies STDs.

Sneezing, nasal itching, rhinorrhea. No sore throat or hoarseness.

No joint pain or swelling.

No lumps or discharge.

No dizziness, weakness, or numbness.

Denies swollen glands, bruising, or cold/heat intolerance.

No depression, anxiety, or sleep disturbances beyond allergy-related nasal obstruction.

Healthy, alert female in no acute distress.

Warm, dry, intact. No rashes.

Head normocephalic.

Eyes: PERRLA, no scleral injection.

Nose: Pale, boggy turbinates; clear discharge.

Throat: Mild postnasal drip, no erythema.

Regular rhythm, no murmurs. Pulses strong.

Clear to auscultation. No wheezes or crackles.

Soft, non-tender. No masses.

No abnormalities noted.

No tenderness or lesions. Normal exam.

Normal ROM.

Gait and balance normal.

Calm, cooperative, oriented.

Pending: CBC with   differential, IgE levels, allergy skin test

None for now

Diagnosis

o    1- Allergic Rhinitis due to Animal (Pet) Dander – ICD-10: J30.81 – This is the most likely diagnosis given the patient’s clear and consistent history of symptom onset following exposure to her pet cat. Her symptoms include persistent sneezing, nasal congestion, clear rhinorrhea, and bilateral eye itching and watering, all of which are characteristic of allergic rhinitis (Wanjia et al., 2022). The fact that her symptoms are triggered in specific environments, particularly at home or in enclosed spaces with the animal, further supports this diagnosis. She reports that she had marginal relief when she started taking antihistamines, and this has occurred for over six months, which can be an incoming allergy, especially when in contact with allergens like pet shed.

o    2- Non-Allergic Rhinitis – ICD-10: J31.0 – Non-allergic rhinitis is an option when symptoms arise when there is no allergic history identified or if the allergy test results are negative. Nevertheless, this condition occurs with nasal blockage and sneezing with clear secretions but lacking the usual features of allergy, such as itching or eye inflammation (Meng et al., 2020). Also, non-allergic rhinitis usually has no specific causal agent linked to the patient’s environment. Nonetheless, given the observation of the patient bearing a known allergen and a flare-up of these symptoms when she is close to them, non-allergic rhinitis cannot be ruled out entirely if routine allergy tests are inconclusive.

o    3- Acute Viral Rhinitis (Common Cold) – ICD-10: J00- Viral rhinitis presents with symptoms that can overlap with allergic rhinitis, such as nasal congestion and discharge. However, it is usually self-limited, resolving in less than 10 days, and often associated with systemic symptoms such as fever, malaise, or sore throat, which the patient does not report (Liva et al., 2021). Considering the chronic and recurring nature of her symptoms and the lack of viral symptoms, this diagnosis is unlikely but may have been considered initially.

Diagnosis

o    Allergic Rhinitis due to Animal Dander – ICD-10: J30.81 – Based on the patient’s clinical history, symptom pattern, exposure to a known allergen, partial response to medication, and lack of evidence for infection or a non-allergic trigger, the most appropriate diagnosis is allergic rhinitis induced by pet dander.

Plan/Therapeutics

§   Further testing – The patient will be referred to an allergist for a comprehensive evaluation, including skin prick testing or serum-specific IgE testing, to confirm sensitivity to animal dander and assess for additional common allergens such as dust mites, pollen, or mold. A complete blood count with differential may also be ordered to check for elevated eosinophils, which can support an allergic etiology.

§   Medication – The patient will begin treatment with fluticasone propionate nasal spray, 50 mcg, administered as two sprays in each nostril once daily. This intranasal corticosteroid will help reduce inflammation and provide symptom control (Remien & Bowman, 2024). She will continue loratadine 10 mg daily, which helps reduce allergic symptoms such as sneezing and itching. In the cases where the symptoms do not recede despite these measures, Montelukast 10 mg daily may be added as an additional therapy, mainly at night or for postnasal drip.

§   Education – The patient was also advised on how to avoid exposure to allergens in the home environment. These include restricting the cat from entering the bedroom and avoiding upholstered furniture where dander accumulates. There was an emphasis on the use of HEPA filters in sleeping and living spaces and vacuuming with HEPA-filtered equipment. Other non-pharmacological measures that were considered included bathing the cat to try to decrease dander shedding. She was instructed to continue using the corticosteroid spray even if she had no signs of the disease for it to remain well controlled.

§   Non-medication treatments – In addition to pharmacological treatment, the patient was advised to use the neti pot or the sterile saline spray two times a day. This is useful in washing allergens from the nasal mucosa for better symptomatic relief (Cabaillot et al., 2020).

In the patient encounter, the patient complied with all that was discussed and appeared to be engaged or attentive to the visit. She had considerable awareness of her medical condition, its risk factors, and the pathology present in terms of the abnormalities. Further, she had knowledge of the pharmacologic and non-pharmacologic management plans for different reasons. This can be evidenced by her openness during the interview, for instance, allowing her to change the physical environment and the schedule for medication. It was evident that she would accept any radical changes in an attempt to abide by the necessary lifestyle changes highlighted. The next appointment has been scheduled for four weeks from the current one to revisit the existing management and also proceed with the allergy test outcomes.