SOAP

Date: 09/24/15 Time: 8:58 AM Age: 33

Sex: F Race: W

Accident Related: Yes__ No_X_ Workers Compensation____ Other_________

Chief Complaint: Nasal congestion, runny nose, cough, headache, pain: nose/cheeks
S: Person reporting events: patient - reliable
HPI: It is a 33 year-old, married factory worker who presents with a 6-day history of
stuffy and runny nose. She was well until 6 days ago when she developed a stuffy nose,
dry, intermittent cough, and clear nasal mucus. Her nasal mucus became greenish-yellow
on the day of her visit (today), and she now requests antibiotics for what she believes is a
sinus infection. She has no history of allergies, or adverse environmental or occupational
exposures. She denies smoking, pets, or using new detergents/products. She complains of
a constant, superficial, generalized, headache and pain rated at 3/10 in her nose and
cheeks when she bends forward. She admits to occasional chills and sweats but has not
taken her temperature. She denies interference with work but limits her social activities
during these episodes. She denies pain in her teeth. She has obtained little relief from the
over the counter decongestants, denies using decongestant nose sprays, and states her
nasal congestion and cough are worse in the evening but that they are constantly present
since the onset of her illness. She has at least one or two “sinus infections” every year and
she cannot seem to get over them unless she takes an antibiotic. She finds some relief
using steam vaporization for 15 minutes before bedtime and denies trying other home
remedies. She prefers sleeping laterally with elevation to her head. Her appetite is
unchanged and she denies history of frequent headaches or other respiratory illnesses.
PMH:
Allergies: No Known Allergies
Current Medications: Oral contraceptives, “religiously,” called “ortho tri cycline”
General – good health with no other complaints (see HPI)
Denies asthma, hay fever, or allergies
Admits to 1-2 sinus infections per year
Two term pregnancies with vaginal deliveries: 2000, 2002
Denies other hospitalizations, surgeries or serious illnesses
Physicals: yearly (last 10/2009), PAP and mammogram, normal
Immunizations: (10/2009) TB; MMR; DPT, Hep B, Rubeola
No recent diagnostics or lab work
Exercises 3 times/week at home for ½ hour (aerobics)
Admits to using safety measures: seat belts, proper lifting techniques with children, and
good lighting
Travel – work daily, one 2-week vacation/year (lake Champlain, “drives”)
Method of birth control: oral contraceptives only
STD test: 10/2009 negative
No recent changes in diet or travel (by car, to work)
FH:
Grandparents:
Maternal grandmother: osteoporosis, arthritis, hypercholesterolemia
Maternal grandfather: prostate cancer, hypertension
Paternal grandmother: deceased, stroke
Paternal grandfather: deceased, MI
Father positive for hypertension and hypercholesterolemia
Mother positive for arthritis
One brother, living/well
Denies family history of hay fever, asthma, allergies or other lung or sinus problems
SH: Patient denies smoking or illicit drug use and admits to occasional alcohol (1-2
beers/month). She admits to having a satisfying, sexually active, monogamous,
relationship with husband for the past 7 years. She is employed on a factory
assembly line (electronics) and does some seasonal farm work with her husband in
the summer.
ROS:
General – Self description: “healthy” except for present complaint; admits weight
stable, diet “healthy”, and performs SBE monthly. Denies fatigue, weakness, or anorexia
Skin/Nails – Denies skin/nail changes; denies skin lesions, pruritis or difficulty healing
Head – Denies dizziness, fainting, or seizures or problems with hair/scalp; admits to HA
x 6 days at 3/10 (see HPI)
Eyes – Denies changes or problems with vision; last eye exam 2 years ago; denies
erythema, pruritis, discharge or use of corrective lenses
Ears – Denies pain, discharge, tinnitus, or hearing loss
Nose – Complains nasal pain and “stuffy and runny” nose with clear mucus (see HPI)
Throat/Mouth – Admits annual dental check ups; denies dysphagia
Cardiac - Denies heart disease, palpitations
Respiratory - Denies lung disease or respiratory difficulty; admits to non-productive
cough (see HPI)
GI – Denies nausea, vomiting, constipation or diarrhea
GU – Denies urinary complaints
O:
VS: Temp. 99.8F (oral); pulse 80 bpm; resp. rate 20; b/p 110/75 mm Hg: pain 3/10 (see
HPI)
General: A & O x 3. No gross deformities or deficits noted
HEENT:
Skin: Warm, pink, dry without lumps, lesions, or inflammation
Head: Normocephalic; scalp pink, mobile, free of scaling
Eyes: Pupils 3 mm, PERRLA. Sclera white; no swelling or lesions
Ears: No gross internal or external abnormalities; hearing present
Nose/Sinuses: Nasal congestion present bilaterally; mucus clear; nasal turbinates
erythematous and edematous. Positive air movement on right nasal passage only.
Frontal/maxillary sinuses non-tender to palpation with positive transillumination

Nodes/Neck: Neck supple without lymph node enlargement/tenderness

Mouth/Throat: Mild posterior pharyngeal cobblestoning present without evidence of
inflammation; lips/oral mucosa moist, pink, without lumps/lesions
Respiratory: Clear to auscultation bilaterally; resonant to percussion
CV: Heart: regular and rhythm without ectopy. Capillary refill < 3 sec. No JVD, edema,
palpitations, or chest pain
GI: BS present, normoactive x 4 quadrants; no palpable masses or organomegaly noted;
denies abdominal tenderness on palpation
GU: Deferred
A:
 Viral upper respiratory infection (URI)
 Bacterial Sinusitis
 Differentials:
• Allergic rhinitis
• Vasomotor rhinitis
• Rhinitis medicamentosa
• Endocrine induced rhinitis
• Hypothyroidism
• Pregnancy
P:
DX: No laboratory tests or imaging studies performed or ordered
TX: Bactrim DS 1 p.o. bid x 3 days #6; Sudafed, as directed; OTC nasal
decongestant spray x 3 days; increase fluid intake; limit dairy; cool mist
humidity
Ed:
Instructions:
RTC if fever or sx unimproved in 3 to 5 days
Use, action, and S/E of meds reviewed
D/c antibiotics if rash or oral mucosal lesions develop and RTC
Adverse effects of prolonged topical decongestants; d/c after 3 days
Sx SJ syndrome reviewed; d/c Bactrim immediately if rash or oral
mucosal lesions develop
Due to antibiotic/oral contraceptive interaction, take additional birth
control precautions
F/U: RTC one week