Directions- You will use this information and make it look like the sample document I sent you. Please use the information and reword into complete sentences like the sample paper. You will need to insert information you will research for certain sections. Please insert your references at the end as the sample paper. APA format. Professional masters level references from American journals. Please include the running head as HEENT SOAP Note

 

Client Information- 26-year-old African American female. 

Chief Complaint- Sinus pressure pain

Allergies- Denies food or medication allergies

Primary Medical History- HA, HTN, arthritis, syncope, cannabis use, sinus infections, anxiety and depression.

Surgical Hx- Tonsillectomy 2013

Social History- She is a nonsmoker, Denies drinking alcohol, or drugs. Married for 4 years. 

Family history- Mother hypertension, hyperlipidemia, and obesity. Alive Father- Diabetes Mellitus, alcoholic Alive

 

HPI- Patient presents today with c/o sore throat. Patient provided verbal consent to be observed and evaluated by NP student. She tells me her symptoms started 1 day ago and have progressively become worse. Her symptoms are associated with fatigue, chills, burning throat, congestion, HA, and sinus pain. She tells me she is generally not feeling well. All 3 of her children are currently being treated with Amoxicillin for strep throat. She has been taking Alka seltzer cold and flu for symptom management with minimal relief. Noted with tenderness around the facial sinuses consistent with sinusitis, redness, and inflammation of the oropharynx, swollen and tender submandibular lymph nodes, bulging and cloudy tympanic membranes bilaterally. 

Physical Exam:

Vital Signs: TEMPERATURE: 99.2   RESPIRATORY RATE: 18   02 SAT (%): 99%   HEART RATE (min): 111    PREVIOUS BLOOD PRESSURE: 120 / 89   BLOOD PRESSURE: 142 / 82, Assessed bi lateral ears, heart, lungs, HEENT assessment. 

 

Review of Systems:

GENERAL: She has been running intermittent low-grade fever since the onset of symptoms 14 days ago. Denies weakness, no fatigue, no chills, no significant weight change

HEENT: Sinus congestion, sinus discharge and her throat is starting to become sore from snorting her post nasal drainage. Swelling of nasal turbinates. Pressure in her frontal forehead area. No blurred vision, itchy eyes, or eye drainage. No ear

pain, loss of hearing, drainage, or pain in ears. No loss of smell. No difficulty swallowing, loss of

taste, change in voice, or sores in her mouth. 

 

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations

or edema.

RESPIRATORY: Denies shortness of breath, dyspnea, cough, or sputum.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

ALLERGIES: Denies history of hives or eczema. She does have a history of seasonal allergic rhinitis and sinusitis.

 

Immunization History: Immunizations current. Flu and pneumonia vaccination received December 2017.

 

 

Neurological: Complains of headache x 2 weeks in the top of her head. No dizziness, syncope, change in mental status, no memory disturbances, no falls or seizures. 

 

Allergic/Immunologic: No deficiencies in immune system

 

Diagnostic results: No diagnostics performed.

 

Differential Diagnoses:

 

CC: Sinus Infection

Acute Bacterial Sinusitis

Put in here information about condition with citations from American journal after 2018 

Acute Viral Sinusitis

Put in here information about condition with citations from American journal after 2018 

 

Upper Respiratory Infection

Put in here information about condition with citations from American journal after 2018 

 

Allergic Rhinitis

 

Put in here information about condition with citations from American journal after 2018 

 

Diagnosis- Acute Bacterial Sinusitis  

 

Plan:

Amoxicillin-clavulanate 875 mg-125 mg oral tablet bid x 10 days

This will be the drug and why it is good to treat sinus infection Put in here information about the drug with citations from American journal after 2018 

 

Steroid Nasal spray This will be the drug and why it is good to treat sinus infection Put in here information about the drug with citations from American journal after 2018 

 

 

Zyrtec 10mg 1 tablet daily This will be the drug and why it is good to treat sinus infection Put in here information about the drug with citations from American journal after 2018 

 

 

Saline Nasal spray- This will be the drug and why it is good to treat sinus infection Put in here information about the drug with citations from American journal after 2018 

 

 

Practice Management- If you fail to improve or worsen by 7 days following initial treatment, please call the office to be reassessed Drink lots of fluid and keep hydrated

 

TREATMENT PLAN: amoxicillin 500 mg oral capsule, 7 days, Directions: Take 1 oral capsule 2 times a day return for follow up appointment x 1 week 

Please find a journal or professional medical source that explains why this drug is the drug of choice for sinus infection. Cite here as well. 

REFLECTION: Rephrase this section This experience has given me the opportunity to apply critical thinking skills to properly diagnose acute bacterial sinusitis, prescribe an appropriate treatment plan, and educate the patient on disease prevention and health promotion strategies based on age, diagnosis, and medical history. This clinical experience along with past knowledge is allowing me to establish a pattern recognition for sinusitis.

 

 

 

 

 

 

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