Soap Note #3                                                                                                               Monday, June 28, 2010 

6/21/10   1000 

 A.S. is a 28 yr‐old Korean female Referral:  None Source and Reliability: Self‐referred; seems reliable  

S‐Subjective:  Chief Complaint:  Cold symptoms  Present Illness:  Pt. reports that she that she has had sinus congestion with green drainage  and HA that started 7 days ago and has gotten worse over the past 2 days. Denies ST and ear pain. Does not know if she has had a fever but does report chills. Pain at the beginning was 3/10 and now is 7/10. Reports using Tylenol Sinus over the past few days without relief of symptoms. Reports having had two sinus infections in the past 10 years. History of seasonal allergies, but does not use medications regularly. Did not assess smoking status.   Past History: Allergies: NKDA                                                                                                                                                       Childhood Illnesses: None                                                                                                                                Medical:  No asthma or recurrent bronchitis.  Surgical: None   Psychiatric:  None               Hospitalizations:  None                                                                                                                                      Health Maintenance:  Immunizations up to date  

Medications:   None 

Family History:  Denies family history of CAD, stroke, heart attack, asthma, cancer, thyroid disease, diabetes, mental illness. 

Social History:  Works at a bank.  Did not assess ETOH, tobacco or drug use. Exercise:  Did not assess Safety measures: Did not address               

Review of Systems 

General: Pleasant and cooperative. Hair and clothing neat in appearance.

Skin: Denies any rashes or skin changes.

Head, Ears, Eyes, Nose, Throat (HEENT): Head: No history of head injury. Ears: Hearing appropriate. Denies vertigo, tinnitus. Eyes: Denies diplopia or blurred vision. Did not assess for last eye exam. Nose: Denies epistaxis. Denies change in sense of smell. Throat: Denies dysphagia or change in sense of taste. Good dentition. Did not assess for last dental exam.

Neck: Denies hoarseness, thyroid or lymph node enlargement.

Thorax and Lungs: Denies cough or SOB. No hemoptysis.

Cardiovascular: Denies orthopnea, CP or syncope.

Gastrointestinal: Appetite good. Denies NV/D. No jaundice, gallbladder or liver problems. No recent changes in bowel habits.

Genitourinary: Denies frequency, dysuria, hematuria or flank pain.

Genital: Did not address

Peripheral Vascular: Did not address

Musculoskeletal: Did not address

Neurologic/Psychiatric: No history of depression or psychiatric conditions.

Hematologic: Denies easy bleeding. No history of anemia

Endocrine: Denies history of thyroid disease and diabetes. Sweating appropriate.

Allergic/Immunologic: None

O-Objective:

Physical Assessment: A.S. is a well nourished female, in no apparent distress. Smiling and interactive in conversation.

Vital Signs: Weight not measured; HR 80; T 100.6; BP 130/85. Height not measured.

Skin: Pink, warm and dry. Nails without clubbing or cyanosis.

Head, Eyes, Ears, Nose, Throat (HEENT): Head: Skull is normocephalic, with injury. Hair with average texture. Ears: Hearing appropriate. Tympanic membrane intact, reddened, dull and full bilaterally. Cone of light noted. Canals reddened bilaterally. Eyes: Sclera white with conjunctiva pink and moist; PERRLA at 3mm; Did not assess optic disc. Nose: Nasal mucosa reddened and moist. Nasal turbinates edematous, no obstruction; septum midline, no frontal or maxillary sinus tenderness. Clear rhinorrhea noted. Throat: Oral mucosa pink and moist. Tongue midline. Pharynx reddened, without exudate. Tonsils 1+. Good dentition.

Neck: Trachea midline. No tenderness or masses. No thyromegaly. Slight non-tender, anterior cervical chain lymphadenopathy.

Thorax and Lungs: Thorax symmetric with good expansion. Lungs resonant. Breath sounds vesicular. No adventitious sounds. No hemoptysis. Did not measure diaphragm excursion.

Cardiovascular: No JVD. Heart sounds S1, S2 with no murmurs, rubs or gallops.

Gastrointestinal: Did not assess.

Genitourinary: Did not assess.

Genital: Did not assess.

Musculoskeletal: Did not assess.

Peripheral vascular: Did not assess.

Neurologic/Psychiatric: Alert and oriented to person and time. Cooperative and pleasant. Interacts in visit. No gross focal, motor or sensory deficits.

Endocrine: Did not assess

Hematologic/Lymphatic/Immunologic: No anemia.

Lab work obtained: None Procedures: None

A-Assessment/Diagnoses

1. Health Maintenance: Immunizations

2. Self-limiting problems: Sinusitis (461.9) DD: URI (465.9 ); Otitis Media (382); Pharyngitis (462)

3. Chronic Health Problems: None

P-Plan

1. Health Maintenance: Immunizations up to date.

2. Self-limiting problems:

1. Amoxicillin 875mg tablets, one PO BID x 10 days; #20; no refills. Instructed to take with food to avoid GI upset. Take all of the medication even if you appear to be getting better. Stop the medication and notify the practitioner for and N/V or diarrhea, SOB, rash.

2. Flonase 2 sprays to each nostril daily; #1; 2 refills. May do one in the morning and one in the evening if so desired. May also use for seasonal allergies PRN.

3. May use cool mist humidification in room by bed at night to keep secretions thin. 4. May use OTC Tylenol or Ibuprofen as needed comfort, HA, and fever. 5. Follow-up with PCP as needed for worsening symptoms or if current treatment is not

successful to treat the condition.

3. Chronic Health Problems: None Christy Holshouser RN, FNP student Sources: McPhee, Stephen J. and Papadakis, Maxine A (2010). Current medical diagnosis and treatment. New York, NY: McGraw Hill. Ferri, F. (2010). Ferri’s Clinical Advisor 5 Books in 1. Philadelphia, PA: Mosby/Elsevier Epocrates Dx: [database for PDA]. Version 3.4. San Mateo (CA): Epocrates, Inc. c2010 [updated 2010 May 23; cited 2010 Jun 10]. Available from http://www.epocrates.com