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463589544-SOAP-NOTE-Sinusitis-docx

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SOAP NOTE
CC: sinus pressure, chills, cold symptoms
HPI
Asian male 35 years old has had 2 weeks of cold symptoms. He had had sinus congestion and
runny nose for 2 weeks with green discharge has gotten worse over the past 2 days. Denies sore
throat and ear pain. He doesn’t know he had fever but had chills. Report that feel the same when
he had a sinus infection last year. He has History of seasonal allergy
Allergies: Seasonal allergy
Medications:
OTC : Tylenol 325 mg PO 2 tabs every 4 hours PRN for pain
PMH : Denies any past illness, injuries or surgeries. Denies Hospitalization.
Social History: denies smoke, normal sleep pattern, healthy diet, exercise, 2 days a week 30
minutes. Single, sexual active with girlfriend. They protect with condoms. Drinks 1 cup of coffee
every day, spiritual believes: God. He drinks socially, denies illicit drug history. He rent a
department.
Family History:
Mother : alive 58 years old, Hypertension
Father: alive 62 , Hypertension and diabetes
Paternal Grandmother: died unknown cause
Maternal Grandmother: died unknown cause
Paternal Grandfather: died unknown cause
Maternal grandfather: died unknown cause
Health Maintenance/ Promotion:
Immunization: children up to date, Influenza overdue, Tdap update
ROS:
General: denies chest pain, Reports chills, malaise, fatigue, and fever. Denies weight change.
Reports fever 101. BMI : 24
Skin: denies rash, itching, denies abnormalities of his nail or hair growth. ?
HEENT
Eyes: denies use of eyeglasses . Denies blurry vision, diplopia, photophobia, eye pain, or change
in vision. denies discharge, watery or itchy eyes.
Ears: Denies hearing loss, ear pain, tinnitus, discharge, or recent ear infections. Denies any
episodes of vertigo. Nose: Denies epistaxis, C/o sinus pain rate 7/10 , reports postnasal drip.
Mouth and Throat:Denies sore throat and difficulty swallowing, denies cough and hoarseness.
Denies bleeding or swelling of gums. Denies any headaches, syncope, or dizziness. Denies any
head injuries, concussions, or periods of loss of consciousness.
CV: Denies chest pain or dyspnea. Denies edema or palpitations or orthopnea. Denies edema or
pain in legs. Denies hands and feet cyanotic.
Respiratory: denies cough , denies SOB and chest tightness . Denies hemoptysis, or pain upon
inspiration or expiration
GI: denies appetite loss, denies weight change. Denies dysphagia, heartburn. Has nausea,
vomiting, denies hematemesis, or intolerance for any food groups. Denies diarrhea. Denies
hemorrhoids, history of ulcerations, gallstones, polyps, or tumors.
Objective
General: Well developed, well nourished, alert, oriented and cooperative, no acute distress
VS: BP:125/70 HR: 90, RR:18 ,Temp.:98.7, Pain: 5/10 Hight:6 Weight: 176??
Skin: warm, pink, dry, and no rashes or lesions. No Bruising or edema. No skin lesions. No nail
lesions, no clubbing, cyanosis or delayed capillary refill.
HEENT normocephalic, PERRL, vision grossly intact, external canal and tympanic membrane
clear, hearing grossly intact. Posterior oropharyngeal edema and erythema, no exudate. Pearly
white sores on tonsils.
Sinus :Tenderness upon palpation to maxillary
Neck: suppler, non-tender, no axillar anterior lymphadenopathy, masses or thyromegaly.
CV: Normal S1 S2 , no murmur ,No S3 or S4. Rhythm regular, no peripheral edema, cyanosis or
pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid
bruits.
Lungs: clear on auscultation, no evidence of wheezing or uses of accessories muscles, no
retractions
Abdomen: Soft, non-distended, no tenderness , No masses. Present Bowel sounds in all four
quadrants. No guarding or rebound. No masses palpable. No organomegaly.
Assessment
Acute Sinusitis
Plan
*Diagnostics : N/A
*Therapeutic
Tylenol for pain
Amoxicillin 875 mg tab PO BID x 10 days
Educational:
- Rest and hydration
-good hand washing Colds and flu are spread primarily when an infected person coughs or
sneezes near someone else. A very common method for transmitting a cold is by shaking hands.
Good hand washing and covering your mouth when you sneeze or cough helps to prevent the
spread of transmission.
*Consultation/Collaboration: N/A
*Follow up :
If symptoms worsen or persist at time of follow up appointment
follou up appointment for annual influenza vaccine
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