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Soap Note Clin Meth 10-15
Soap Note Clin Meth 10-15
Soap Note Clin Meth 10-15
Donald Davis
10/15/2017
S. Addie Adler a 53 year old white female presents in the clinic today with complaints of “feeling like my
head is going to explode.” Pt reports that she has been having this problem for two weeks that has
progressively gotten worse over this period of time. Pt reports that has an achy pressure in her head just
above and below her eyes. Pt denies any vision problems, itching, headache, hearing problems, or sore
throat. Pt does report that she has had a runny nose with drainage being clear at the beginning and now
turning a yellowish green color today. Pt does also have a dry unproductive cough and dry mouth. Pt
denies any other breathing problems except for the cough. Pt reports that she has taken Mucinex over
the last two weeks with no relief. Pt does also report that she has felt fatigued and has slight trouble
sleeping. Pt has not seen another healthcare provider for this problem.
Review of Symptoms
Constitution: Pt does have a fever, fatigue, and problems sleeping due to cough. Pt also has increased
pressure in frontal and maxillary sinuses.
EENT: Pt has no vision, throat, or ear problems. Pt does have yellow green rhinorrhea.
Pmhx.
Pt has a mucus retaining cyst in maxillary. Pt has also had sinusitis in the past treated with antibiotics.
Family Hx
Social Hx
Pt is a paralegal in a law office. She is not married walks in the evening for exercise and is a non-smoker
and non-drinker.
Transillumination of frontal and maxillary sinuses: No light able to seen on either exam
Palpation: Pt had pain in both frontal and maxillary sinuses with palpation
Nasal exam with otoscope: Pts nasal passages were red and swollen
A. 1. Bacterial Sinusitis
2. Viral Sinusitis
3. Allergic rhinitis
P. Eval and treat with cervical adjusting, lymph massage, sinus adjustment with activator. Recheck in
two days.