S.O.A.P Note William Frederick Completed by: Marissa Huettman

Subjective:

CC: Worsening HA, Facial Pain, Fever

HPI:

William, a 42 yo male presents with 14 day history of headaches following an URI. He notes

headaches are worsening in intensity, 7-10 day history of facial pain, intermittent right tooth

pain, sinus pressure, post-nasal drip that is cloudy and worsens at night, and recent onset of

today right ear pain, which he notes is stabbing. Pt also admits to low grade fevers that began

today, 100 F at home. He has taken Tylenol and sinus OTC medications with no relief. He finds

changing positions and sleeping is also painful and notes that steam showers has helped

discomfort some. Of note, patient is newly diagnosed diabetic who has not had follow up and

also a pertinent history of environmental allergies.

PMH:

Hypertension- 6 years

Hypercholesterolemia- 6 years

Psoriasis- childhood

Type II Diabetes Mellitus- Dx 11 months ago.

Obesity

Surgical: Appendectomy- 29 yo

SH:

Marital Status: Married- no sick contact

Recent Travel: Denies

Diet: Traditional American diet- high in meat and carbs

Smoking: previous ½ pack a day x 20 years. Quit 4 years ago.

EtOH: 1-3 beers during the week, 2-4 beers weekends

Recreational substance use (past and present): Marijuana- highschool

FH:

Father- 71 y/o obesity, CAD

Mother- 69 y/o obesity, hx of diabetes

Maternal GM: Diabetes, deceased age 72, sepsis r/t LE amputation

Maternal GF: Hx CV disease, deceased age 78, MI

Paternal GM: Deceased age 82, MI

Paternal GF: HTN, deceased age 80, MI

Brother: 47 yo obesity, diabetes

Sister: 39 HTN

Medications:

Metformin, 500 mg po BID

Simvastatin 20 mg po Q HS

HCTZ 25 mg po daily

Multivitamin daily

OTC: Tylenol ES, Tylenol cold and flu, Advil, Naproxin – all as needed.

Allergies: Environmental: Grass, mold, trees, dust

Immunizations: UTD, does not get annual Flu shot

ROS:

General: +Fever, +Fatigue, Denies: Usual weight, recent

weight change, weakness, night sweats, anorexia, malaise

Skin: Denies: Color changes, pruritus, bruising, petechiae,

infections, rashes, sores, changes in moles, changes in hair or

nails

Head: +Headache, head injury

Eyes: Denies: Vision, glasses/contact lens, date of last eye

examination, pain, redness, excessive tearing, double vision

(diplopia), floaters (spots in front of eyes), loss of any visual fields,

history of glaucoma or cataracts

Ears: +right ear pain, Denies: Hearing loss, change in hearing,

ringing in ears (tinnitus), ear infections

Nose and Sinuses: +sinus pain, discharge, post nasal drip,

Denies: Frequent colds, nasal stuffiness, hay fever, nosebleeds

(epistaxis), obstruction, change in ability to smell, sneezing,

history of nasal polyps

Mouth and throat: +right tooth pain, Denies: dryness, ulcers,

sore tongue, bleeding gums, pyorrhea, sore throat, hoarseness,

history of recurrent sore throats or of strep throat or of rheumatic

fever

Neck: Denies: Lumps, swollen lymph nodes or glands, goiter

(thyroid enlargement), pain

Lymphatics: +Swollen lymph nodes in neck, axillae,

epitrochlear areas, or inguinal area

Pulmonary: Denies: Cough (duration, association with sputum

production), change in chronic cough, trouble breathing

(dyspnea), wheezing, coughing up blood (hemoptysis), pain with

taking a deep breath (pleuritic chest pain), blue discoloration of

lips or nailbeds (cyanosis), history of exposure to TB, history of a

previous TB skin test and the results if done, recurrent

pneumonia, history of environmental exposure

Cardiovascular: Denies: Chest pain (including details), dyspnea,

paroxysmal nocturnal dyspnea (abbreviated "PND"; patient will

describe shortness of breath that improves when he or she sits up

and dangles feet off the bed), orthopnea (patient has to sleep on

pillows to prevent shortness of breath; quantitate by the number

of pillows that the patient sleeps on), edema, palpitations,

hypertension, known heart disease, history of a murmur, history

of rheumatic fever, syncope or near syncope, pain in posterior

calves with walking (claudication), varicosities, thrombophlebitis,

history of an abnormal electrocardiogram

Gastrointestinal: Denies: Trouble swallowing (dysphagia), pain

with swallowing (odynophagia), nausea, vomiting, vomiting blood

(hematemesis), food intolerance, indigestion, heartburn, change

in appetite, sensation of filling up earlier than usual (early

satiety),frequency and character (formed vs. loose) of bowel

movements, changes in bowel pattern, rectal bleeding, passing

black tarry stools (melena), constipation, diarrhea, abdominal

pain, excessive belching or passing of gas, hemorrhoids, jaundice,

liver or gallbladder problems, history of hepatitis

Urinary: Denies: Blood in urine (hematuria), pain on urination

(dysuria), frequency, suprapubic pain, costovertebral angle (CVA)

tenderness, frequent urination at night (nocturia), passing large

volumes of urine on a frequent basis (polyuria), stones, inguinal

pain, trouble initiating urinary stream, incontinence, history of

urinary tract infections

Musculoskeletal: Denies: Joint pains or stiffness, arthritis, gout,

backache, joint swelling or tenderness or effusion, limitation of

motion, history of fractures

Neurologic: +Headaches Denies: Fainting, blackouts, seizures,

paralysis, local weakness, numbness, tingling, tremors, memory

changes, vertigo or dizziness, muscle atrophy

Endocrine: Denies:Thyroid trouble, heat or cold intolerance,

excessive sweating or flushing, diabetes, excessive thirst or

hunger or urination, change in glove or shoe size

Objective:

Poorly groomed, obese male, standing, Pt appears to be feeling ill but is in no apparent distress.

Appears older than stated age.

Vitals:

HR: 82

BP 112/80 Standing, 130/82 Sitting

RR: 18

Temp: 99.8 F oral

Ht: 6’

Wt: 215

Physical Exam:

CV: RRR

Resp: WNL, no labored breathing or distress

Pertinent+: purulent posterior nasal secretions, mild erythema to posterior oropharynx.

Erythematous, edematous and swollen turbinates with discharge noted, right ear tympanic

membrane erythematous, poor movement and light reflexes. Frontal sinus pain to palpation.

Mildly enlarged right neck lymph nodes.

Test Results:

CBC: Elevated WBC (11,000) with left shift

CMP: Elevated BG (158)

Rapid Strep: Negative

Assessment:

Differential Diagnosis:

1 Sinusitis

2 URI

3 Allergic Rhinitis

Plan:

Rx: Amoxicillin/clavulanate 875 mg/125 mg PO BID for 7 days.

Pt may take IBU 400mg q 6 hours as needed for pain.

Pt to return to clinic or present to ER in 48 hours if symptoms worsening or he develops changes

in vision, severe unilateral headache or changes in mental status. Pt agreeable to plan and will

also pick up OTC nasal decongestant (Neo-Synephrine) to decrease nasal congestion and

promote drainage. Pt was educated on use of Netipot for symptom relief as well. He is aware to

use this at most for 3 days. Discussed with patient the use of warm compresses on face,

frequent steam showers and increasing oral fluids as well.

Discussed with patient lab results. Pt is agreeable to follow up with PCP in 2 weeks for follow up

labs, including fasting BS, A1C and lipid panel- new lab order provided to have drawn. Pt also

aware that he will need more routine follow up for his complex medical diagnosis. Discussed

obesity with patient and familial risk factors for heart disease. Pt is agreeable to follow up with

PCP about seeking a weight management plan and discussion with nutritionist for diet.

Pt has no further questions or concerns and is agreeable to plan.