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Solved Soap note about Acute Frontal Sinusitis.

Solved Soap note about Acute Frontal Sinusitis.

Soap note about Acute Frontal Sinusitis.

Answer:Soap note about Acute Frontal Sinusitis.

CHIEF COMPLAINT (CC): “I have a sore throat, stuffy nose, and pressure across my
forehead and face.”
HISTORY OF PRESENT ILLNESS (HPI): J.S. is a 35 year old male who presents to the
clinic today complaining of a sore throat, nasal congestion, and sinus pressure for the past 2
weeks. States his wife and kids got sick first, after which his symptoms began. He reports their
symptoms resolved pretty quickly, however, he is “just not getting better.” States he is unable to
breathe through his nose and feels pressure across his forehead, in between his eyes, and
bilaterally on each side of his nose that increases when he first gets out of bed in the morning or
bends down. States it does not radiate anywhere. Reports a nonproductive cough as well. His
symptoms last throughout the entire day. States he has been taking Sudafed, Advil, and a saline
nasal spray for the past 10 days which makes him feel better for a few hours and then as the
medicine wears off he feels worse than before he took the medicine. Reports working long hours,
not getting enough sleep, and smoking more than a pack of cigarettes a day. Soap note about Acute Frontal Sinusitis.
MEDICAL HX (PMH):
Childhood: No significant childhood illnesses or injuries.
Adult: No current health issues as an adult. No past surgical history. No psychiatric issues.
Social: smokes 1 ½ packs of cigarettes per day for 12 years (18 pack-years). Denies past or
present illicit drug use. Reports social alcohol use. Married with 3 kids. Does not exercise.
Medications:
Sudafed 1-2 tablets Q4-6hr PRN
Advil 200-400mg (1-2 tablets) Q4-6hr PRN
Saline Nasal Spray 1 spray per nostril TID PRN
Immunizations: Currently up to date on all immunizations. Flu vaccine 11/2015.
ALLERGIES: No known allergies.
Family History: Mother has hyperlipidemia. Father has hyperlipidemia and hypertension.
Health Maintenance: J.S. was advised to make a follow up appointment for a routine physical
examination to recheck blood pressure (pre-hypertension) with family history of father having
hypertension, check cholesterol levels due to family history of hyperlipidemia (mother), discuss
diet/exercise, and smoking cessation.
REVIEW OF SYSTEMS:
General: Complains of fatigue. Unsure of fevers (never checked temperature) but complains of
intermittent chills. Denies recent weight changes. Denies any lymphadenopathy.

Integumentary: Denies any rashes, lumps, sores, itching, or dryness. Denies any changes in
color or bruising easily.
HEENT: Head: Complains of sinus pressure and tenderness. Denies lightheadedness or
dizziness. Eyes: Denies eye pain, redness, excessive tearing, or blurred vision. Ears: Complains
of ear fullness. Denies tinnitus, vertigo, discharge, or earache. Nose: Complains of nasal
congestion, decreased smell, post-nasal drip, and inability to breathe through nose. Denies
itching, sneezing, or nosebleeds. Throat: Complains of soreness, irritation, and mouth breathing
which is causing dry mouth. Denies bleeding gums.
Neck: Denies lymphadenopathy, lumps, pain or stiffness in neck. Soap note about Acute Frontal Sinusitis.
Respiratory: Complains of nonproductive cough. Denies any shortness of breath, dyspnea on
exertion or wheezing.
Cardiovascular: Denies chest pain, palpitations, or swelling.
Gastrointestinal: Denies nausea, vomiting, or change in bowel habits. Complains of decreased
appetite the past 2 weeks and throat hurting when swallowing.
Urinary: Denies hematuria, burning or pain during urination.
Musculoskeletal: Complains of generalized body aches. Denies joint redness, tenderness,
swelling, or limitation of motion or activity.
Vital Signs: Temp: 98.8, HR: 85, BP: 148/85, RR: 20
Height: 75 inches, Weight: 205 pounds, BMI: 25.6 (Overweight)

Soap Note Acute Frontal Sinusitis

PHYSICAL EXAM:
APPEARANCE: Pleasant & cooperative male. Appears tired but in no acute distress.
HEENT: Head: Normocephalic/atraumatic. Symmetric. Normal hair distribution and
pattern. Eyes: PERRLA. EOMI. Conjunctiva pink. Sclera white. No redness or drainage
noted. Ears: Tympanic membrane intact, dull and full bilaterally. Cone of light noted.
Ear canals clear bilaterally. Nose: Nasal mucosa reddened and moist. Septum midline.
Nasal turbinates edematous, no obstruction. Thick and purulent drainage noted. Frontal
and maxillary sinus tenderness. Throat: Oral mucosa pink and moist. Tongue midline.
Pharynx reddened, without exudate. Tonsils 1+. Good dentition.
NECK: Supple. Trachea midline. No tenderness or masses. No thyromegaly. No
lymphadenopathy.
CV: Regular rate and rhythm. Normal S1 and S2 auscultated. No murmurs. No S3 or S4
auscultated.
PULMO: Lungs resonant and clear bilaterally. No use of accessory muscles or distress
noted. Nonproductive cough noted. No hemoptysis.
ABDOMEN: Soft, nontender. Active bowel sounds.
PELVIC/GU/RECTAL: Assessment deferred.
EXTREM: Normal gait. No obvious deformities. Normal range of motion in extremities.
No peripheral edema. No joint pain, tenderness, or edema.
NEURO: Alert and oriented x4. Normal strength and tone in all muscles. No gross focal,
motor or sensory deficits. Full neurological assessment deferred.
LAB/DIAGNOSTIC TESTS/EKG: Strep test negative. Soap note about Acute Frontal Sinusitis.

IMPRESSION/PLAN : Soap note about Acute Frontal Sinusitis.
Diagnosis: Acute Sinusitis (J01): This diagnosis was made based on symptoms and physical
examination. Symptoms have been present for 14 days without improvement, most likely
b; acterial.
Soap note about Acute Frontal Sinusitis.Differential Diagnoses: Allergic Rhinitis (J30.9)- ruled out because symptoms not associated
with allergens and pt c/o chills and possible fevers; Upper Respiratory Infection (J06.9)- ruled
out d/t persistent symptoms for at least 14 days with no relief; Acute Pharyngitis (J02.9)- ruled
out no pharynx exudates and negative strep test.
Treatment Plan: 
1. Amoxicillin-clavulanate 875/125mg tablet PO BID x 7 days.
2. Flonase 2 sprays in each nostril daily.
3. May use cool mist humidifier in bedroom at night to keep secretions thin.
4. OTC Tylenol or Ibuprofen 1-2 tablets PO Q4-6hrs PRN for comfort, HA, and fever.
5. Plenty of fluids and rest
No further lab work or diagnostics required at this time.
Education: Instructed to take antibiotic with food to avoid GI upset. To take all of the
medication even once you start to feel better. Stop the medication and notify the provider if
nausea, vomiting, diarrhea, shortness of breath or rash develop. Additional education given
regarding good hand washing and increasing fluid intake. Discussed with patient cutting back on
hours at work if possible until symptoms resolve and he is feeling better. Education completed
regarding the importance of a healthy diet, exercising for at least 30 minutes 3-5 times per week,
and getting an adequate amount of sleep each night. Educated patient regarding smoking
cessation and provided information on assistance to do so. Patient voiced no desire to quit at this
time. Refused nicotine patch or any additional medications or resources.
Follow up: Instructed to follow up with PCP if experiencing worsening symptoms, if current
treatment is not successful to treat the condition, or new symptoms/side effects develop.

References

  1. Gupta, A. K. (2015). Sinusitis. In The 5-minute clinical consult premium 2016 (24 th ed., pp.
    1028-1029). Philadelphia, PA: Wolters Kluwer.
  2. Hall, M. (2013). Sinusitis. In Primary care: A collaborative practice (4th ed., pp. 376-379). St.
    Louis, MO: Elsevier/Mosby.
  3. Sinusitis (Sinus Infection). (2015). National Institute of Allergy and Infectious Diseases.
    Retrieved from http://www.niaid.nih.gov/topics/sinusitis/Pages/Index.aspx

Question:

Soap note about Acute Frontal Sinusitis. With 3 well explained Differential Diagnostic

 

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