Advanced Nursing SOAP Note
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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