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Posted: March 18th, 2023

SOAP Note #2 Acute Sinusitis

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:

PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:

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Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:

Objective Data:
VITAL SIGNS:

GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:

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ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.
Differential diagnosis (minimum 4)
-
-
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• -
• -
Pharmacological treatment:
-
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals
References (in APA Style)

Discussion Topic: Soap Note 2 "Acute Sinusitis"

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______________________
SOAP Note #2

Main Diagnosis: Acute Sinusitis

Patient Information
Name: John Doe
Age: 32
Gender at Birth: Male
Gender Identity: Male
Source: Self-referred
Allergies: Penicillin
Current Medications: None
PMH: Asthma, seasonal allergies
Immunizations: Up to date
Preventive Care: Annual physical exam, regular dental check-ups
Surgical History: Tonsillectomy at age 16
Family History: Father with high blood pressure, mother with breast cancer
Social History: Non-smoker, occasional alcohol use
Sexual Orientation: Heterosexual
Nutrition History: Balanced diet, no special restrictions

Subjective Data
Chief Complaint: "I have a bad headache, facial pressure, and my nose is congested and runny."
Symptom analysis/HPI: John reports the onset of symptoms four days ago. He has been experiencing a headache that is worse in the morning, facial pressure and pain around his eyes, and congestion with yellowish-green nasal discharge. He also reports a decreased sense of smell and taste. He has tried over-the-counter nasal decongestants and pain relievers, which provided only temporary relief.

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Review of Systems (ROS)
CONSTITUTIONAL: No fever, chills, or weight loss.
NEUROLOGIC: Headache and facial pain.
HEENT: Nasal congestion, runny nose, decreased sense of smell and taste, and facial pressure.
RESPIRATORY: No cough or shortness of breath.
CARDIOVASCULAR: No chest pain or palpitations.
GASTROINTESTINAL: No nausea, vomiting, or diarrhea.
GENITOURINARY: No urinary symptoms.
MUSCULOSKELETAL: No joint pain or muscle aches.
SKIN: No rash or lesions.

Objective Data
VITAL SIGNS: Blood pressure 120/80 mmHg, heart rate 80 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6°F.
GENERAL APPEARANCE: Alert and oriented, in no apparent distress.
NEUROLOGIC: Cranial nerves II-XII intact, no focal deficits.
HEENT: Mild tenderness to palpation over maxillary and frontal sinuses, yellowish-green nasal discharge, no tonsillar enlargement or erythema.
CARDIOVASCULAR: Regular rhythm, no murmurs or rubs.
RESPIRATORY: Clear to auscultation bilaterally, no wheezing or rales.
GASTROINTESTINAL: Soft and non-tender.
MUSKULOSKELETAL: No joint swelling or deformities.
INTEGUMENTARY: No rash or lesions.

Assessment
John Doe is a 32-year-old male presenting with symptoms of acute sinusitis. He reports a headache, facial pressure and pain, nasal congestion with yellowish-green discharge, and decreased sense of smell and taste. On physical examination, there is tenderness to palpation over the maxillary and frontal sinuses, and yellowish-green nasal discharge. There are no signs of complications such as periorbital swelling or fever. These findings are consistent with acute bacterial sinusitis.

Differential Diagnosis:

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Allergic Rhinitis
Viral Sinusitis
Chronic Sinusitis
Migraine Headache
Plan

Order a CT scan of the sinuses to confirm the diagnosis and assess for complications such as orbital cellulitis or abscess.
Prescribe Amoxicillin-clavulanate 875 mg PO twice daily for 10 days to treat the bacterial infection.
Prescribe intranasal cort icosteroids such as Fluticasone propionate 50 mcg/spray, 1 spray in each nostril once daily to reduce inflammation and improve symptoms.
Prescribe decongestants such as Pseudoephedrine 60 mg PO every 6 hours as needed for congestion relief.

Non-Pharmacologic treatment:
Advise the patient to use saline nasal irrigation to help reduce congestion and improve sinus drainage.
Recommend warm compresses over the affected sinuses to alleviate pain and discomfort.

Education:
Advise the patient to complete the full course of antibiotics even if symptoms improve to prevent the development of antibiotic-resistant bacteria.
Instruct the patient to avoid allergens and irritants that can trigger sinusitis.
Educate the patient on proper hand hygiene and respiratory etiquette to prevent the spread of infection.

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Follow-ups/Referrals:
Schedule a follow-up appointment in 2 weeks to assess response to treatment and evaluate for any complications.
Refer the patient to an allergist or immunologist if chronic or recurrent sinusitis is suspected.

References:
American Academy of Otolaryngology-Head and Neck Surgery. (2021). Clinical practice guideline (update): Adult sinusitis. Retrieved from https://www.entnet.org/content/adult-sinusitis

Centers for Disease Control and Prevention. (2022). Antibiotic prescribing and use in doctor's offices. Retrieved from https://www.cdc.gov/antibiotic-use/community/about/antibiotic-prescribing-and-use-in-doctors-offices.html

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