Sinus congestion Write SOAP note for the

Sinus congestion Write SOAP note for the following scenario: Include: From the scenario, you are not obligated to use all of the history or ROS information provided. Read this scenario as if you were listening to one of your clients. Subjective & Objective – Document details to support diagnosis and r/o of differential diagnoses. One diagnosis, 2 differentials and rationale to support diagnosis and criteria for ruling out differential diagnoses. Diagnostic testing that you would order if any. Why/why not? Plan of care – covering key areas per SOAP template and rubric for grading Site source of evidence-based rationale for assessment and plan of care. A female presents with c/o sinus congestion she is 56 years old and has tried over the counter treatments that have not worked. Symptoms include: headache, runny nose, post nasal drainage. Headache is located above eyes. Hearing is muffled. Symptoms worse over past 2 days. Tried Neti pot 2x/day, little relief. Claritin D and Zytrec D without relief of symptoms. Normally OTC meds provide good relief for her seasonal allergies. Two months ago was treated with amoxicillin 500 mg 3x/day for 10 days. Symptoms, minimal improvement so was then treated with Augmentin 875 mg 2x/day for 10 days. Symptoms resolved, but with in a week, sinus symptoms returned. Other history: sinusitis 2-3 times /year for past 10 years. Suffers from seasonal allergies both spring and fall. Had allergy testing 2009 and treated with allergy shots x 1 year, then stopped – “minimal relief”. Brother has asthma and season allergies. Has had no surgeries. No others medical history pertient. Goes up North fishing and camping at least 2x/month over past 6 months. “Bought a new piece of land up north, 6 months ago”. Smokes couple cigarettes on weekends when going out with friends and has 2-4 beers/week. Does not use recreational drugs. Mother and dad have high blood pressure. Meds: Flonase 2 sprays each nostril at hs when needed. Takes Claritin D or Zyrtec D daily when needed. ROS: include pertinent negatives, you would ask about, to support r/o of your differential dx. EXAM: Vitals: Wgt 154#, BP 124/80 LA sitting, P 84 reg, R 20, T 98.4 oral General Appearance: alert, no distress and cooperative. Other details: conjunctivia/corneas clear, retracted TM’s and pearly gray with landmarks present. Heart regular, no murmurs, normal rhythm. Tender frontal sinuses bilaterally. Nose has no deformity or asymmetry, clear thin mucous present. Nasal mucosa appears swollen. Mouth has no redness or petechiae, halitosis, post nasal drainage or exudates. Clear lung sounds with even respirations. No rashes. Neck soft, supple, no adenopathy or tenderness. TMs intact, gray landmarks present. Resource: (recommend using UpToDate)

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