Please review, edit and complete soap note use currently evidence based guidelines SUBJECTIVE: Patie

Please review, edit and complete soap note use currently evidence based guidelines SUBJECTIVE: Patient: LL DOB 05/25/1990 34yo Gender: Female Chief Complaint: “I’ve had a cough, runny nose, and congestion for a week and a half, now I am starting to have really bad headaches.” HPI: LL is a 34-year-old female who presents with a 10-day history of cough, rhinorrhea, nasal congestion, and postnasal drip. Symptoms began gradually, with a runny nose and congestion worsening over the course of a few days. Patient describes nasal discharge as initially clear, but it has become more yellow over the past week. She has also been experiencing a dry, intermittent cough that worsens at night due to postnasal drip. For the past two days, she reports the development of a dull, pressure-like headache and sinus pain localized over the frontal and maxillary sinuses, which intensifies when bending forward. She denies fever, chills, or significant changes in the severity of her cough. However, she notes that her headaches and sinus pain have been progressively worsening over the last two days, prompting her visit today. The patient has tried using over-the-counter decongestants and saline nasal spray with minimal relief. She also mentions that her 1-year-old daughter was recently sick with a cold, suggesting a possible source of exposure. LL has a history of asthma, but she denies any shortness of breath, wheezing, or exacerbation of her asthma symptoms. PMH: Seasonal allergies, Asthma Past Surgical HX: No surgical history reported Medications: Symbicort 160 mcg/4.5 mcg- 2 puffs inhaled BID Immunizations: · Influenza- 10/10/23 · COVID-19- Dose 1 Pfizer 6/15/21, Dose 2 Pfizer 7/8/21 · Tdap- 09/9/2016 Allergies: season allergies, NKDA, no food allergies Family HX: Both parents alive, 2 siblings- No pertinent family history reported Social HX: Non-smoker, drinks alcohol socially1-2x/month. Works remotely. Lives with her husband and 1-year-old daughter. Exercises 3 times per week. Health Care Maintenance: Reports last annual wellness visit with PCP was 8 months ago, no issues reported. Patient reports regular dental visits every 6 months. Last OB-GYN visit 9 months ago postpartum, currently sexually active with one partner, has IUD for contraception, Review of Systems: General: Denies fever, chills, fatigue, or weight changes. Head: Reports headaches, sinus pressure. Denies dizziness dizziness, numbness, weakness, or tingling, or recent trauma. Neck: Denies pain, stiffness, or lymph node enlargement. Eyes: Denies eye pain, drainage, or vision changes. ENT: Reports runny nose, nasal congestion, postnasal drip, sinus pain, and cough. Denies sore throat or ear pain. Respiratory: Denies shortness of breath or wheezing. Reports occasional dry cough. OBJECTIVE: Vital Signs: T-98.6, BP 121/73, RR 18, HR 60, SpO2 99% HT: 5’6″ WT: 119 BMI: 19.2 Physical Examination: Appearance: AAOx3, no acute distress, posture upright. Patient appears well nourished and well groomed. Maintained eye contact and engaged in conversation. Head: normocephalic, atraumatic, no swelling or visible abnormalities. Neck: supple with full ROM. Carotids +2 bilaterally. No lymphadenopathy or tenderness, trachea midline. Eyes: No conjunctival injection, PERRLA. No conjunctival injection, PERRLA. ENT: Tympanic membranes intact, clear with out fluid bilaterally. Nose midline, no deviation. nasal mucosa appears erythematous with mild swelling, clear to yellow discharge noted. Sinus tenderness present over the maxillary and frontal sinuses. Throat mildly erythematous without exudate. Respiratory: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. LABS/DIAGNOSTIC TESTS/EKG: None ordered at this time IMPRESSION/PLAN: DIFFERENTIAL DIAGNOSES Ruling In: · Acute Bacterial Rhinosinusitis (J01.00): Considered due to the duration of symptoms (>10 days) and worsening headaches/sinus pain. Although the patient does not present with high fever, a diagnosis of bacterial sinusitis is possible. Ruling Out: · Acute Viral Rhinosinusitis (J01.90): Symptoms are consistent with a viral etiology, including congestion, sinus pressure, and postnasal drip without fever. Viral sinusitis can be exacerbated by upper respiratory infections, which may explain her daughter’s recent illness as a source. · Allergic Rhinitis (J30.9): Could account for runny nose and congestion, but less likely due to the presence of sinus pain and history of recent sick contact. ASSESSMENT/PLAN: LL, a 34-year-old female, presents with symptoms consistent with Acute Bacterial Rhinosinusitis (ABRS), including persistent nasal congestion, runny nose, postnasal drip, and cough for over 10 days without improvement, aligning with they American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) diagnostic criteria. She reports recent worsening, with new sinus pain and headaches following initial congestion, a “double-worsening” pattern typical of bacterial infection. Her nasal discharge, initially clear, has thickened and turned yellow, further indicating bacterial involvement. The pain is localized to the frontal and maxillary sinuses, worsening when bending forward. Her 1-year-old daughter’s recent cold may have been the viral trigger leading to this secondary bacterial infection. Although LL does not have a fever, this is common in uncomplicated ABRS, and the diagnosis is supported by prolonged symptoms, worsening patterns, and classic sinus pain and congestion. Drug Therapy: Amoxicillin-Clavulanate 875 mg/125 mg: One tablet twice daily for 10 days Brompheniramine-pseudoeph-DM 2-3-10mg/5ml syrup: Take 5ml every 4-6hrs for 5 days Patient Education: Increased fluid intake to help thin mucus and keep hydrated. Use a humidifier to keep air moist, which can help with congestion. Apply warm compresses to the face to alleviate sinus pain. Complete full course of prescribed antibiotic; do not stop taking antibiotic even if you start to feel better. Rest and avoid excessive physical exertion until symptoms improve. Sleep with head elevated Avoid smoking or being around people who smoke. Call or return if symptoms persist beyond 7-10 days of antibiotic therapy or if they worsen. Asthma: Monitor for any exacerbation of symptoms, particularly shortness of breath or wheezing. Report to ED or call 911 if experiencing symptoms of worsening headaches, constant vomiting, swelling or pain around face or eyes, vision changes, confusion, or trouble breathing. Follow up: Ø Return in 48-72 hours if symptoms do not improve or worsen. Health Maintenance · Schedule annual wellness visit with PCP · Flu vaccine due (CDC, 2024) · OB/GYN- cervical cancer screening and pap every 3 years (USPSTF, 2023) · Annual Anxiety and Depression Screening (USPSTF, 2023) · Screening for Hep B, Hep C, STI/HIV (USPSTF, 2019) · Incorporate healthy diet that consists of fruits, vegetables, whole grains, fat free/low fat dairy products, lean proteins (USPSTF, 2020) · Continue physical activity of 150 min of moderate intensity or 75 min of vigorous aerobic activity per week (USPSTF, 2020) Concluding Thoughts: The diagnosis of acute bacterial rhinosinusitis (ABRS) is supported by the patient’s symptom duration of more than 10 days, the worsening of symptoms with the onset of headaches and sinus pain, and a history of recent upper respiratory infection in her child, suggesting possible exposure. The absence of significant fever makes a viral etiology less likely. According to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines, the use of antibiotics is indicated for patients with symptoms persisting beyond 10 days without improvement, as well as those with severe symptoms such as fever and purulent nasal discharge or facial pain lasting for 3-4 days consecutively. First-line treatment includes amoxicillin-clavulanate for 5-7 days in uncomplicated cases. The plan of care aligns with current evidence-based practices, with recommendations for supportive measures to manage symptoms and prevent exacerbation of asthma. Proper follow-up ensures that treatment is effective, and any need for adjustment in therapy can be promptly addressed.

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