SOAP Note for a Patient Presenting with Acute Sinusitis

SOAP Note for a Patient Presenting with Acute Sinusitis

SUBJECTIVE

ID: A.D. is a 28-year-old male. He is Asian/Filipino. He is a reliable historian. He presents to the clinic alone.

CC: “I’ve got extreme nasal congestion, a runny nose, and watery eyes. I also sneeze frequently and am feeling some irritation around my nose.”

HPI: A.D. is a 28-year-old Filipino male presenting with complaints of nasal congestion, rhinorrhoea, watery eyes, and sneezing. The symptoms began two days ago after an evening walk in their family’s garden. The symptoms are primarily located in the eye and nasal regions and have been worsening over the past 24 hours. He is currently sniffling and clearing his throat frequently. His symptoms are aggravated by the consumption of cold food substances and alleviated by drinking a hot beverage. The symptoms persist during the day and at night. However, they are severe during the morning but ease as the day progresses.

PMH: A.D. has had similar symptoms in the past. He reported that two years ago, he developed similar symptoms and was diagnosed with allergic asthma and treated in an outpatient facility. He was also diagnosed with allergic rhinitis when he was 20 years old. Far from that, he has been healthy.

• Surgeries and hospitalizations: D. has no history of surgeries or any hospitalization. He also denies having experienced any accidents or head injuries in his life.
• Immunizations: D. is up-to-date with all his immunizations, including the annual flu and COVID-19 vaccines. He received his second booster for the COVID-19 vaccine six months ago.
• Allergies:D. is allergic to animal dander, pollen, and dust. He denies being allergic to any medication.
• Medications: A.D. is currently on Tylenol and an unknown multivitamin caplet. He noted that he was advised to take the medications at the onset of his symptoms by his brother.

Family History: A.D. has a family history of allergic rhinitis and allergies. He noted that his mother is allergic to animal dander. His father frequently suffers from allergic rhinitis and is on allergen immunotherapy. He has two brother siblings, all of whom are not afflicted with any illness.

Chemicals: A.D. is a binge alcohol drinker and a social smoker. He noted that he drinks mostly during parties and smokes occasionally during social events. He denied using any other substance of abuse, including illicit drugs.

Diet/exercise/caffeine: A.D. diets regularly but enjoys vegetables. He drinks seven glasses of water daily and rarely eats fast foods. He takes two cups of coffee or tea every morning. He exercises mildly in his free days but lacks an exercise routine.

Sexual/Reproductive History: A.D. is sexually active. He noted that he indulges in protected sex regularly with his girlfriend. He denies having any congenital anomalies in his reproductive system and genitalia. He also denies having had any sexually transmitted infections.

Social History:

• Occupation/marital/relationship/military status & current living situation:D. is a software engineer. He currently lives with his brother in a rented space. He is in a monogamous relationship with his girlfriend, whom he plans to marry. He denies ever serving in the military. He noted that his current living situation is good, as he can access all social services. He loves skating.
• Spiritual/Social Supports: D. is a staunch Christian. He regularly attends church and has strong ties with his church members. He participates in social activities and is even a chairperson of a welfare group within his neighborhood. His family is a source of his social support as he consults them in all aspects of his life.
• Safety: D. pays close attention to safety recommendations, such as putting on a helmet when skating. He also wears a seat belt when driving. He denies owning a gun, driving, or drunk driving.

Review of Symptoms

Constitutional: Denies any changes in weight, fever, and chills. Reports appetite loss and fatigue.

Eyes: Denies vision loss or double vision but reports having teary eyes over the past two days.

ENT: Denies hearing loss or tinnitus. He has nasal discharge, nasal congestion, and sniffles frequently. He also reports having some nasal pruritus and sore throat since morning. He denies anosmia.

CVS: Denies chest pain, lower limb edema, or irregular heartbeats.

RESP: A.D. has difficulty breathing, clears throat frequently, and produces excessive mucus. He denies any wheezing and cough.

GIT: Denies any abnormal bowel movement and sound.

GU: Denies any urinary frequency, urgency, or painful urination

Musculoskeletal: Denies any muscle tenderness, pain, or edema. He also denies having any limitations in his range of motion.

Skin: Denies any skin lesions, skin discoloration, scaling, swelling, or moles on the skin.

Neurological: Denies memory loss, syncope, tingling sensation in the extremities, or dizziness.

Psychiatric: Denies having any mental health illness.

Hematologic/Lymphatic: Denies lymph swelling, bleeding, easy bruising, or anemia.

Endocrine: Denies experiencing excessive thirst, frequent urination, heat and cold sensitivity, hair loss, and noticeable shifts in energy.

OBJECTIVE

Vital Signs:

• Temperature: 98.6 degrees Fahrenheit
• Blood Pressure: 126/ 81mmHg
• Pulse rate: 90 bpm
• Respiratory rate: 21 bpm
• SPO2: 96%

Physical Examination

• General survey: D. is awake and oriented to place and event. He is well-hydrated but looks fatigued. No signs of discomfort or distress.
• Head: Normocephalic, hard, smooth with no lesion, swelling, or tenderness. Hair is consistent in coloration and evenly distributed, with no oiliness or dryness seen. Facial movements are symmetrical, with no signs of drooping.
• Eyes: The eyes are symmetrical and evenly spaced. He has watery discharge from both eyes. There was no signs of nystagmus or strabismus. The eye movements, peripheral view, and reflex are intact.
• Ears: The ears are symmetrical, with ear pinnae normal in shape. The ear coloration was also consistent with other parts of the head region. No ear discharge seen on inspection. There was also no sign of ear swelling, tenderness, or swelling on both ears.
• Nose:The nose is symmetrical and midline, with no tenderness, swelling, discoloration, or nasal lumps. Notable nasal discharge with frequent nose sniffling. There were no scars, lesions, nasal distortion, or septal deviation.
• Mouth/Throat:The oral cavity is midline. The tongue movement was intact. Two tonsils were noted at the back of the mouth. No swelling, tenderness, or lesions were noted in the mouth and throat.
• Neck:No discoloration scars, lumps, nodal enlargement, or lesions noted on the neck region. The neck movements were intact.
• Cardiovascular:The heart rate was rhythmic, with no heart sounds heard. There was no swelling on the lower extremities.
• Resp: No respiratory or breath sounds heard on auscultation. There were also no wheeze sounds, crackles, or rales. There was notable respiratory distress.
• Abdomen/GI:The abdomen was soft to the touch. No abdominal pain, lesions, tenderness, scars, or masses on palpation. Bowel sounds heard in all four abdominal quadrants.
• GU: Tympanic sounds heard on percussion of the bladder. There was no swelling, tenderness, or lumps on palpation of the bladder region. No pain or tenderness on the suprapubic region.
• Skin: The skin is warm to touch, moist, and consistent in color and texture. No scars, lesions, moles, or tendernesswere  noted.

ASSESSMENT

Differential Diagnosis

1. Allergic rhinitis, ICD 10 Code J30.9

Allergic rhinitis is an upper respiratory disease; it is atopic. It manifests with symptoms of clear rhinorrhoea, watery eyes, nasal congestion, and nasal pruritus. The disease proceeds from exposure to allergens such as animal dander and pollen, with subsequent modulation of inflammatory responses. Integral to the diagnosis process of the disease is history taking. In this respect, a detailed history taken upon establishing symptom presence is necessary. Family history of allergies and allergic rhinitis, history of allergies and past allergic rhinitis diagnosis, recent exposure to an allergen, and onset of symptoms within 24-48 hours of exposure to an allergen may point towards allergic rhinitis diagnosis (Nur Husna et al., 2022). The patient, in this case, presented with symptoms consistent with those of allergic rhinitis. Additionally, subjective findings revealed that he was allergic to pollen and dander, had potential exposure to an allergen, had symptoms onset of less than 24 hours, and had a family history of allergies and allergic rhinitis. This warranted the inclusion of this differential.

2. Vasomotor rhinitis, ICD 10 Code J30.0

Vasomotor rhinitis is a non-allergic form of rhinitis. It presents with symptoms similar to those of allergic rhinitis. However, in vasomotor rhinitis, there is no relation to a specific allergen. Additionally, it may affect non-atopic individuals. Strong odors, colds, and spices have been thought to trigger this disease (Liva et al., 2021). A.D., the patient, presented with symptoms consistent with those of vasomotor rhinitis. This diagnosis was, however, ruled out because the patient was atopic. Additionally, subjective findings revealed that the onset of the symptoms proceeded with a potential exposure to an allergen.

3. Non-allergic rhinitis with eosinophilia syndrome (NARES), ICD 10 Code J31.0

NARES is a clinical syndrome that comprises manifestations of allergic rhinitis and the absence of atopy, demonstrated by an allergen test. The nasal cytology results in NARES reveal eosinophils of more than 20%. Anosmia is also prominent in the disease (Meng et al., 2020). In this case, the patient presented with symptoms similar to those in NARES. It was, however, ruled out because of the absence of anosmia and other supporting features of NARES.

Final Diagnosis: Allergic rhinitis, ICD 10 Code J30.9

PLAN

The patient will be subjected to a skin allergy test to further rule out NARES and vasomotor rhinitis. He will be started on cetirizine 10mg administered orally every 24 hours on a PRN basis. Cetrizine, a second-generation antihistamine, maintains effectiveness in the management of allergic rhinitis. It can be used as a monotherapy or in combination with other agents to manage allergic rhinitis. It is less sedating compared to the first-generation agents and may thus be favorable for the patients (Sharma et al., 2022). The potential side effects of cetirizine include dizziness, headache, mouth dryness, and GI disturbances. Other agents that can be used as alternatives to cetirizine include first-generation antihistamines such as chlorpheniramine, leukotriene antagonists such as montelukast, and oral decongestants such as pseudoephedrine.

Education

The patient is advised to take the medication only when symptoms are apparent. He is also educated on the potential side effects of cetirizine. Centrizine is a second-generation antihistamine that has less potential for sedation. Notwithstanding, mouth dryness, dizziness, GI disturbances such as constipation, and headache may be apparent. He should return to the clinic whenever his symptoms fail to resolve after seven days of therapy for further evaluation. He should also have plenty of rest and check out for fever as this may indicate bacterial involvement and, therefore, warrant prompt antibiotic therapy.

Follow-Up

The patient is expected to return to the clinic after seven days if the symptoms fail to resolve.

References

Liva, G., Karatzanis, A., & Prokopakis, E. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183

Meng, Y., Yan, B., Wang, Y., Wu, D., Zhang, L., & Wang, C. (2020). Diagnosis and management of nonallergic rhinitis with eosinophilia syndrome using cystatin SN together with symptoms. World Allergy Organization Journal, 13(7), 100134. https://doi.org/10.1016/j.waojou.2020.100134

Nur Husna, S. M., Tan, H.-T. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic rhinitis: A clinical and pathophysiological overview. Frontiers in Medicine, 9. https://doi.org/10.3389/fmed.2022.874114

Sharma, K., Akre, S., Chakole, S., & Wanjari, M. B. (2022). Allergic rhinitis and treatment modalities: A review of the literature. Cureus. https://doi.org/10.7759/

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Assignment Prompt
• For your note this week, create a HEENT-related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and a treatment plan in a full SOAP note format. Use an HEENT-related CC that a patient would present within a primary care setting (i.e. no emergency room or ICU type complaints. Examples: sore throat, ear ache, hearing loss, eye drainage, etc.).

• Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use the PA title page, citations, and reference format. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow-up).
• The ROS and physical exam in your document should be written up as they would be for a problem-focused visit. The HEENT part of the physical exam write-up should be a comprehensive write-up, including everything you assessed in your recording.
• Submit this SOAP write-up and the video in the assignment tab
*** I will be the one creating the video, just created a HEENT-related complaint for a 28-year-old Male, I attached a sample

ID: AD
Age: 28 years old Male
Asian/ Filipino
Reliable Historian
Gender: Male ( preferred pronoun – He/Him)

Chief Complaint: This is the one we need to create and then SOAP