SOAP Note: Recurrent Sinusitis

SOAP Note Name Course Institution Instructor Date   Recurrent sinusitis SOAP Note Student Name: ___________________________________________________ SUBJECTIVE Identifying Data Sandy is a 64-year-old female patient with a 10-year history of recurrent sinusitis.   Chief Complaint:  Patient C/O that she had a "cold" last week with symptoms of cough and "runny nose and a headache that was relieved using Tylenol. History of Present Illness:  Sandy She complains of head congestion, had a cold" last week and cough and "runny nose. Two days ago, she developed a headache that worsened when bending over but improved with Tylenol. Sandy reported the headache as frontal and rates it as 3 out of 10. She is also concerned with nasal congestion worsening with the discharge from her nose became thicker, with a yellow-green color.  Using pseudo-ephedrine for the 2 days barely provided relief of her nasal congestion. Past Medical and Surgical History:  Sandy does not report tooth pain or pain on chewing and has no past history of seasonal allergies. However, she was treated for sinusitis 6 months ago in your clinic and 1 year ago.   Medications/Allergies Tylenol to treat headache Pseudo-ephedrine for nasal congestion She has no past history of seasonal allergies Pertinent Family History:  The family has no significant history of illnesses or psychiatric issues Pertinent Social History Sandy’s 10-year history of recurrent sinusitis has affected her health over the period. •           Level of education completed -N/A •           Marital status -N/A •           Living Status: -N/A •           Occupation: No exposure to environmental toxins •           Social support/ family/community •           Habits:  No drinking and smoking problem,  •           Any stressors- Her health status is a stressor Review of Systems: Eyes:  No reported eye exams  Nose:  She has a runny rose and has increasingly been blowing her nose in the past few months. Sandy complained of nasal congestion Throat and mouth: Did not report problems with mouth breathing, but there is a risk of this because of nasal compression nod inability to breathe through the nose. Cardiovascular:  Denies chest pains and congestion Respiratory:  Has symptoms of cough, but has not reported wheezing or shortness of breath,  Gastrointestinal:  No report on changes in bowel habits.  Musculoskeletal: No report of body aches, tenderness or swelling  Extremities: n/a Psychiatric: No psychiatric issues were reported Nursing Data base Sandy’s medical condition is interfering with her daily activities, but her health beliefs and behavior dot affect her willingness to seek medical attention   OBJECTIVE Objective Physical Exam    Constitutional: Respiratory distress and issues with the ear, nose, and throat.  Vital signs are: blood pressure: 128/88; Pulse: 78 and regular; Respiratory rate: 20 p/min, non-labored.Her temp taken at the clinic is 99.6°F....