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Practicum Experience SOAP Note

Name: Patrick Ackah

University: Purdue Global University

Course: MN569 FNP I Clinical- Life span Health focus

Professor: Monica Antolin

Date: 06/23/2021
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Practicum Experience SOAP Note

Subjective

Chief complaint (CC): MR. E. is a 56-year-old male patient presented the clinic with

complaints of a headache and congestion.

HPI: The patient indicated that the onset of the pain was three days ago but had

worsened on the fourth day. The patient states that he feels pain and tenderness on his forehead,

below the eyes, as well as the sides of the nares. The patient also indicates that he experiences

congestion, and some coughing accompanies that. The cough is usually dry, and it gets worse

during the night. The patient describes the heading as throbbing, which is worsened by cough.

The patient also reports a runny nose with a discharge that is yellow in colour. Currently, the

patient reports that he has been using Advil and Mucinex to manage the condition, but the

effect does not last long. Mr. E also indicates that while he does not have trouble performing his

daily activities, he has been unable to work for the last two days.

Medications: 200mg Advil, 1200 mg Mucinex per day.

PMH

Allergies: NKDA

Medication Intolerances: N/A

Chronic Illnesses/Major traumas: N/A

Hospitalizations/Surgeries: N/A

Family hx: Patient’s mother is alive but has hypertension. Patient’s father died five years ago

due to lung cancer.

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Social hx: Patient is divorced, has two daughters, and they keep in contact. He lives alone and is

employed at a local general store as the delivery driver and handyman at the store. HE does not

smoke but drinks an average of 3 beers per week.

Pertinent ROS

Head: retro-orbital forehead and maxillary sinuses are tenderness to touch

Eyes: pink conjunctiva and white sclera

Ears: pearly grey bilaterally

Nose: nasal mucosa shows a bilateral yellow mucus plugs blocking the turbinate’s, swelling

noted to nasal bridge, cheeks pharynx mildly erythema, uvula midline, tonsils 1 + bilaterally,

lymph nodes non-palpable neck- supple no palpable masses upon palpation

Respiratory: lung sounds clear bilaterally throughout

HEART: denies and chest pain or SOB

ABD- denies any abdominal symptoms upon examination.

Musculoskeletal- denies any back, muscle, or joint pain.

Neurological - denies any bowel or bladder incontinence.

Psychiatric – no signs of depression, no self-reported suicidal thoughts.

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Objective

Vital Signs

Weight: 175, T: 97.8 °, P: 85, RR: 18, BP: 118/86. Height: 6’3, BMI: 29.9

General Appearance: Healthy in appearance, alert and oriented, answers questions appropriately.

Skin: pale, warm, and clean. Patient does not have rashes or lesions.

HEENT: Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canal’s

patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose:

Nasal mucosa pink; normal turbinate. No septal deviation. Neck: Supple. Full ROM, no occipital

nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is no erythematous and

without exudate. Teeth are in good repair.

Cardiovascular: S1, S2 with regular rate and rhythm. Pulses 3+ throughout. No edema.

Respiratory: Symmetric chest wall. Respirations are regular and easy; lungs clear to auscultation

bilaterally.

Gastrointestinal: BS active in all four quadrants. Abdomen soft, non-tender

Breast: Breast is free from masses or tenderness, no discharge, no dimpling, or discoloration of

the skin.

Genitourinary: Bladder is non-distended; no CVA tenderness. Both testes palpable, no masses or

lesions, no hernia, no urethral discharge

Musculoskeletal: Full ROM seen in all four extremities as the patient moved about the exam

room. Right index and pointer finger numb.

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Neurological: Speech clear. Balance stable, gait normal

Lab Tests: N/A

Special tests: N/A

Assessment

Differential Diagnosis

The patient is likely affected by the following three conditions in order of their

likelihood.

Acute Sinusitis: This is the most likely condition based on the patient’s subjective and

objective data. Both acute and chronic sinusitis cause similar symptoms that the patient reported,

including throbbing headaches, nasal congestion, and purulent rhinorrhoea. In addition, the

condition is also associated with productive coughs that occur at night. The affected sinus may

be swollen and tender, which results in pain, and congestion. The mucus secretion is usually a

reaction to the infection, which means that treatment will help clear the condition. Thus, the

headaches, cough, congestion, and obstruction of the airways are the symptoms that indicate that

the patient is likely being affected by acute sinusitis.

Allergic Rhinitis: This is another likely condition based on the patient’s reported

symptoms and the objective data. The patient indicates that he feels that the nasal passages are

congested, which is a key symptom of allergic rhinitis. However, coughing, and nasal mucosa

obstruction that obstructs the view of the turbinate are not a symptom of allergic rhinitis. As

such, further investigation might be needed to ascertain the condition.

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Rhinovirus Infection: The rhinovirus is the most common viral infection in the world.

The virus mostly infects areas that have a constant temperature of between 33 and 35o C. Such

conditions are found in the nose, which makes them ideal parts of the body to be affected. The

symptoms of the condition include coughing, nasal congestion, secretion of mucus that ranges in

color, fatigue, and muscle aches, among other problems. The patient's subjective and objective

information indicates that the first two symptoms are present while the others are absent. As

such, the likelihood of rhinovirus infection is low, considering some of the symptoms are absent.

Plan/ Education

An antibacterial drug will be an appropriate medication for the patient to relieve the

indicated symptoms. According to Miravitlles et al. (2012), a yellow mucus indicates that the

infection is likely to be bacterial and not viral. As such, the patient will prescribe Augmentin oral

tablets, 875 mg. He will take medicine twice a day for ten days. His current regimen will also be

adjusted to ensure that the medication is effective for long periods. First, Advil will be adjusted

from 200mg per day to 600 mg. Next, the patient will be prescribed three orals’ tablets to be

taken three times a day. Mucinex will not be adjusted, and the patient will be advised to maintain

his current regimen for seven days. Augmentin will help treat the infection, while Advil will

help to reduce headaches and pain in the sinus. In addition, Mucinex will help to reduce

congestion and help expel the mucus in the patient’s sinuses.

Patient Education.

Patient was educated on some self-help steps can help relieve sinusitis symptoms:
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 Encouraged to drink copious amount of water to relieve the nasal congestion.

 Rest. This will help your body fight infection and speed recovery.

 Moisten your sinus cavities. Drape a towel over your head as you breathe in the

vapor from a bowl of hot water. Keep the vapor directed toward your face. Or

take a hot shower, breathing in the warm, moist air. This will help ease pain and

help mucus drain.

 Rinse your nasal passages. Use a specially designed squeeze bottle (Sinus Rinse),

This home remedy, called nasal lavage, can help clear your sinuses.

References

Miravitlles, M., Kruesmann, F., Haverstock, D., Perroncel, R., Choudhri, S. H., & Arvis, P.

(2012). Sputum colour and bacteria in chronic bronchitis exacerbations: a pooled

analysis. European Respiratory Journal, 39(6), 1354-1360.