Running Header: PCII SOAP NOTES #1

SOAP Notes #1

PCII SOAP NOTES #1

Location: CMT JUNCOS Date/Time: 10/26/11 9:15 am

Patient Profile/Identifying Data: 50 y/o male comes to the clinic complaining of flu-like symptoms. (S) Patient comes to the clinic complaining of flu-like symptoms. Pt complains of myalgia, headache behind the eyes and cheeks, some fever. Headache worse when bending over. Pt reports symptoms have been going on for 3 days. Reports taking Tylenol cold medicine. (-) for sore throat, cough, nausea, vomiting. T 36.7 Ht 67 Wt 195 lbs. HR 72 RR 18 BMI 140/85 General Appearance: AOx3. Patient appears in mild discomfort. HEENT: NC/AT, PEERLA, Ears- no erythema, no drainage, TM intact, Throat- no erythema or exudates, Neck- supple, no masses/LAD. Maxillary and frontal sinuses tender on palpation. Cardiovascular: NRR, no audible murmur Pulmonary: Clear to auscultation bilaterally ABD: Soft, tender to palpation in epigastric area. No palpable masses. NBS. Labs: Maxillary and frontal sinus x-ray show opacity in maxillary sinuses

(O)

(A): 50 y/o male presenting with frontally located headache, myalgia, maxillary tenderness and fever for 3 days. Diagnosis: Sinusitis

Differential: URI, Influenza, Tension Headache, Common Cold Patient did not display any of the coryza symptoms associated with URI or common cold. Patient described headache as located behind eyes, and on cheek bones indicated sinusitis, not the classical band-like description of tension headaches. (P) The primary goals of management of acute sinusitis are to eradicate the infection, decrease the severity and duration of symptoms, and prevent complications. Also, patient

PCII SOAP NOTES #1

presented with elevated BP of 140/85 likely due to use of OTC cold medications. Discussed with patient the need to follow/up with PCP for continued monitoring of BP. Medication: Amoxicillin 500 mg PO bid x 14 days Tylenol Cold and Sinus 500 mg PO BID prn for fever and headache x 7 days Initial selection of the appropriate antibiotic therapy should be based on the likely causative organisms given the clinical scenario and the probability of resistant strains within a community. The course of treatment is usually 14 days. First-line therapy at most centers is usually amoxicillin or a macrolide antibiotic in patients allergic to penicillin because of the low cost, ease of administration, and low toxicity of these agents. Amoxicillin should be given at double the usual dose (8090 mg/kg/d), especially in areas with known S pneumoniae resistance. (Lobel, 2009) Oral alpha-adrenergic vasoconstrictors, including pseudoephedrine and phenylephrine, can be used for 10-14 days to allow for restoration of normal mucociliary function and drainage.

Labs: None at this time Tests: Maxillary and Frontal Sinus X-ray Education: Safety belt, Sun protection, alcohol abuse screening and education Follow/up: Patient to remain until x-ray comes back. If symptoms due not resolve or worsen, return to clinic for reevaluation.