Comprehensive SOAP Note for a Patient with Sinusitis

Sinusitis

 

This is a comprehensive SOAP note of a patient with sinusitis.

• Primary diagnosis: Sinusitis
• Differential diagnosis: Cold, Trigeminal Neuralgia, Migraine

No cover page References no older than 3 years. Please use proper medical terms for all assignments.

 

Comprehensive SOAP Note for a Patient with Sinusitis

 

Patient’s Details

Initials: J.R.             Age:  36 years                       Race: Hispanic                      Gender: Male

SUBJECTIVE:

Chief Complaint (CC): “I have a sore throat, a stuffy nose that is preventing me from breathing through the nose, a runny nose, and a headache with facial pain. The facial pain worsens when I bend forward.”

History of Present Illness (HPI): J.R. is a 36-year-old Hispanic male who has visited the clinic today unaccompanied complaining of a sore throat, a stuffy and runny nose, and a headache with facial pain. J.R. indicates that the facial pain worsens when he bends forward. These symptoms have lasted for about 2 weeks. Although the symptoms are getting better, J.R. reports that they are resolving slowly and he is concerned that they might recur when he fails to get treatment. J.R. cannot breath through the nose due to nasal congestion. He also feels some slight pressure on his forehead. The pressure together with a headache even prevent him for rising up comfortably whenever he is lying down. His current symptoms do not radiate to other parts of the body. J.R. further states that he took two tablets of paracetamol three times a day 3 days ago to help relieve the headache and the facial pain. However, the facial pain and the headache reoccurred a day later. As indicated by J.R., his work is quite involving and sometimes he has to work long hours before going home. The symptoms have affected his ability to work but he is optimistic that he will be fine when he finally gets treatment.

III. Past medical history (PHx)

1. Childhood illnesses

J.R. reports that he can recall having asthma during his early adolescent years but he was treated without hospitalization. He however denies being diagnosed with any serious medical condition apart from that except for the occasional fevers.

1. Immunizations

Medical records indicate that J.R. received all immunizations according to schedule. He received hepatitis B vaccine 1^st and 2^nd doses, rotavirus vaccine 1^st and 2^nd doses, measles, mumps, rubella (MMR) vaccine, and diphtheria, pertussis, and tetanus (DPT) vaccine. Other vaccines that he has received include polio vaccine, varicella, hepatitis A, and pneumonia vaccines. His last influenza vaccine was on 17/11/2022.

1. Adult Illnesses

J.R. denies having any serious illness during adulthood. He occasionally experiences headaches when he has a lot of work to do but these usually resolve when he uses painkillers.

1. Operations

Denies a history of surgery.

1. Allergies

No known drug or food allergies reported.

1. Medications

J.R. is not using any medications at the moment. He took paracetamol two days ago to relieved the facial pain and he headache.

1. Complimentary treatments

He denies use of complementary treatments.

1. Family history

J.R. is the second born in a family of three children. His father and mother are both alive. The mother is 62 years old and the father is 68 years old. The mother was diagnosed with hyperlipidemia two years ago while the father is healthy. Maternal grandmother has diabetes whereas grandfather is deceased. His paternal grandparents are both deceased.

1. Social history

J.R. is a mechanical engineer at a nearby construction company. He is married with one kid and stay with his family in the city. His wife is a nurse and she is employed at a nearby hospital. J.R. denies consuming cigarettes, alcohol, or illicit substances like heroin and cocaine. The family’s typical diet comprises of the five major food groups including carbohydrates, proteins, minerals, fruits, and vegetables. J.R. rarely engages on physical activities but he occasionally walks to work when he leaves home early. He works hard every day to ensure that his family gets basic needs such as food, clothing, shelter, and healthcare. They have a family health insurance that caters for medical bills whenever a family member falls sick.

1. Review of Systems

General: Denies abnormal weight gain or significant weight loss in the recent months. Reports chills, fever, and fatigue. Reports discomfort due to the nasal congestion, headache, and facial pain. His last medical examination was done 2 years ago.

Skin: The skin color matches the patient’s race. Denies itchiness/pruritus, rashes, or lesions. Denies redness, bruises, or petechiae. Denies change is hair or nail color.

HEENT:

Head: Denies physical injury on the head. Reports a headache.

Eyes: Denies excessive tearing redness, or eye pain. Reports pressure around the eyes. Denies vision-related problems. Does not report a history of cataracts or glaucoma. J.R. does not use contact glasses. Date of last eye examination was 2 years ago.

Ears: Reports fullness in the ears, especially during cold weather. Denies hearing loss, ringing in the ears, ear infections, or pain in the ears. Denies a history of vertigo, tinnitus, or earache.

Nose and sinuses: Reports nasal congestion and runny nose. Reports difficulty breathing through the nose. Denies a history of nasal polyps. The nasal congestion has caused reduced smell. Denies sneezing or nasal itching. Reports facial pain around the sinuses.

Mouth and throat: Reports soreness and irritation of the throat. Reports on-productive cough. Reports breathing through the mouth due to nasal congestion. This causes dryness in the mouth. Reports a bad breath. Reports mild aching of the teeth. Does not report mouth ulcers. Denies pyorrhea. Denies hoarseness of the throat. No history of bleeding gums or strep throats reported. Denies dental carries.

Neck: Denies neck pain. Denies the presence of lumps in the neck region. Does not report swollen lymph nodes. Denies goiter or a history of thyroid enlargement.

Lymphatics: Denies swollen axillae or lymph nodes in the inguinal and epitrochlear areas.

Breasts: Denies discomfort, pain, lumps, or discharge from both breasts.

Pulmonary: Reports breathing difficulties through the nose. Reports a cough. Reports fatigue. Does not report hemoptysis. Denies pleuritic chest pain, wheezing, cyanosis, recurrent pneumonia, or a history of tuberculosis. Reports a history of asthma.

Cardiovascular: Denies dyspnea or orthopnea. Denies palpitations, denies edema. Denies a history of cardiovascular problems. Denies chest pain, irregular heartbeat, or heart murmurs. No history of high blood pressure, myocardial infarction, or rheumatic fever reported.

Gastrointestinal: Reports odynophagia or pain when swallowing food. Denies abdominal pain. Denies indigestion or heartburn. Denies vomiting or nausea. No changes in bowel movements reported. Does not report diarrhea, constipation, excessive belching, a history of jaundice, or a history of gallbladder problems. Reports changes in appetite. Denies rectal bleeding.

Urinary: Denies dysuria or pain in the genitals during urination. Denies hematuria or the presence of blood in urine. Denies a reduction in urine volume. No history of urinary tract infections reported.

Genital tract (male): Denies a history of a sexually-transmitted disease (STD). Denies pain in the genitalia. Denies swelling in the testicles. No penile discharge or hernias reported.

Musculoskeletal: J.R. reports stiffness or swelling on joints. Denies a history of fractures, backache, or limitations of motion. Denies a history of gout, arthritis, or backache.

Neurologic: Denies blackouts or seizures. Denies tingling, tremors, or numbness of limbs. Denies muscle atrophy, changes in memory, or dizziness. Reports a headache that occur together with facial pain. Reports fatigue.

Psychiatric: Denies irritability, nervousness, nightmares, depression, insomnia, anxiety, or tension. J.R. denies suicidal ideation or a history of serious mental illnesses. He also denies hypersomnia.

Endocrine: Denies excessive thirst, abnormal sweating, or excessive hunger. No thyroid issues reported. Does not report heat or cold intolerance. Denies excessive urination. Denies a history of diabetes.

Hematologic: J.R. denies easy bruising, anemia, or abnormal bleeding. He also denies a history of blood transfusion or reactions.

VII. Physical examination

Vital signs: Temperature; 37.6 degree Celsius, Blood pressure; 120/75, respiratory rate; 20 breaths per minute, pulse; 92 beats per minute, weight; 158.4 lbs.

General appearance: J.R. looks tired but he can maintain eye contact during conversation. He is neatly dressed and appropriately oriented to time, place, and person. He is breathing through the mouth and has a runny nose.

Skin: Skin is warm, intact, and without rashes. No evidence of cyanosis on the nail beds. Nails are without ridges.

HEENT:

Head: No evidence of trauma. Head is normocephalic. Absence of depressions or palpable masses. Hair is of normal texture. No signs of alopecia. Hair is evenly distributed throughout the scalp.
Eyes: No evidence of lesions or swelling of the eyelids. PERRLA. Pink conjunctivae. No signs of hemorrhage of conjunctivae. No evidence of icterus on sclerae. No signs of redness/erythema noted.

Ears: No evidence of discharge or blockage in the ear canal. No tenderness or edema on the external ear and ear canal. A pale grey color is observed in the tympanic membrane.
Nose: Nasal mucosa is hairy, pink, and moist. The nasal septum is at the midline position. Edematous nasal turbinates observed. No evidence of nasal obstruction. Drainage of thick greenish mucus is noted from the nose. Tenderness of both frontal and maxillary sinuses.

Mouth/Throat: Oral mucosa is moist and pink with good dentition on the gums. Gums are slightly erythematous. Oral mucosa is without lesions or ulcers. Evidence of sores in the throat. The pharynx is erythematous and without signs of edema or tonsillar exudates.

Neck: No abnormal pulsations or masses observed. Trachea is positioned midline. The neck is supple without lesions or bruits.

Nodes: The inguinal, axillary, and epitrochlear nodes do not have signs of swelling.

Chest: No crackles, wheezes, rhonchi, or rubs. Normal breath sounds noticed.

Heart: Regular heart rate or rhythm. No noise on a bilateral basis. Normal heart rate, S1, S2, without galloping, murmurs, or rubbing. Midclavicular PMI visible, 5th intercostal region, no heaves, lifts, or excitement. No evidence of edema on the periphery. Varied bilateral peripheral pulses, capillary refill less than 3 seconds.

Abdomen: No evidence of tenderness, pain, or distention. Abdomen is soft and protuberant, no scars. Normal bowel sounds active in all four quadrants. To evidence of hernia on palpation.

Back/spine: No signs of trauma or external skin changes observed. Back and neck have no signs of deformity. J.R. has an upright posture with a steady gait within normal limits. No tenderness on the back and spine. No curvature of the spine noted.

Extremities, including exam of pulses: No evidence of stiffness, tenderness, or swelling of the joints. No palpable pulses in the upper and lower extremities. Lower extremities are atraumatic.

Genitalia/Rectal: Hair is evenly distributed on the pubic area. No lesions or masses observed on the penis. No signs of suprapubic pain on palpation. The testes are non-tender and without lesions. No evidence of rectal hemorrhoids.

Neurologic:

Mental status: J.R. is attentive and able to concentrate. His level of consciousness is good. No issues with language, speech, or memory.

Cranial nerves: Crania nerves II-IX are intact. Full EOM observed. Evidence of visual fields.

Motor: No signs of muscle rigidity. Normal gait and good balance. All joints have a muscle strength of 5/5.

Sensory: Reflexes are 2+ on upper and lower limbs. Lower and upper limbs are sensitive to touch and pricking.

VIII. Problem list

• Sore and erythematous throat
• Nasal congestion or stuffiness
• Runny nose
• Drainage of thick greenish mucus from the nose
• Difficulty breathing through the nose
• Breathing through the mouth
• Headache
• Facial pain that worsens when the patient bends forward
• Pressure around the eyes
• Fatigue
• Fever
• A mild cough
• Aching in the teeth
• Altered sense of smell
• Bad breath coming from the mouth

1. ASSESSMENT

• Sinusitis (Acute)

1. Differential Diagnosis

• Cold
• Trigeminal neuralgia
• Migraine

X1. Plan:

1. Diagnostic (labs etc.)

• Strep test
• Nasal endoscopy
• Computed tomography (CT) scan of the sinuses and nasal region

1. Medications

• Decongestants
• Nasal corticosteroids
• Saline nasal spray (Flonase)

1. Referral

• No referrals are necessary at this time

1. Patient Education

Your diagnosis today is acute sinusitis. This conclusion has been made because the symptoms that you are currently experiencing match those of sinusitis. It is acute sinusitis because the symptoms have not lasted for more than 12 weeks to warrant the chronic type. You will be given Flonase which you will be required to spray in your nostrils twice daily. You will also use Tylenol to relieve the pain. You should adhere to the prescribed medication and report to the clinic in case you develop problematic symptoms or complications such as vision problems. Engage in mild exercise daily, dress in warm clothing, and eat a diet rich in vegetables and fruits.

1. Follow-Up: Visit the clinic for evaluation after two weeks.

 

References

Arcimowicz, M. (2021). Acute sinusitis in daily clinical practice. Otolaryngologia Polska, 75(4):40-50. doi: 10.5604/01.3001.0015.2378. PMID: 34552023.

Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13^th ed. Philadelphia: Wolters Kluwers.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Mayo Clinic. (2022). Acute sinusitis. https://www.mayoclinic.org/diseases-conditions/acute-sinusitis/symptoms-causes/syc-20351671

Perkins, B. N. (2019). Incidence and treatment of acute sinusitis in two outpatient primary care settings and provider challenges in treating adult sinusitis. DNP Projects, 294. https://uknowledge.uky.edu/dnp_etds/294

Saltagi, M. Z., Comer, B. T., Hughes, S., Ting, J. Y., & Higgins, T. S. (2021). Management of recurrent acute rhinosinusitis: A systematic review. American Journal of Rhinology & Allergy, 35(6), 902-909. https://doi.org /10.1177/1945892421994999.