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:
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:
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”
______________________
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.
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:
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.
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
