FNP 592 Week 2 SOAP Notes: Clinical Documentation Template

• Clinical Documentation Template

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Student Name and clinical course: __________(FNP 592)

Client’s Initials*:__XX_____Age__45___ Race____American______Gender___Female_________Date of Birth_January 1, 2000__________

Insurance ____Yes___________ Marital Status___Married__________

Subjective:

CC: “I have experienced body aches, congestion, and headaches in the last ten days.”

HPI: The patient, with a 10-day complaint of body pain, congestion, and headaches, is a 45-year-old American female who presented herself to the clinic. At this point, she says that her symptoms are managed with Mucinex and Ibuprofen. She has a mild headache, body pain, and intermittent chills that are related to nasal congestion. These symptoms are exacerbated by the seasonal changes. The final body temperature recorded at home was 99 degrees. She scores her pain in her body as 4/10 and relieves it with the help of Mucinex and Ibuprofen, but it comes back in an hour. Denies vomiting, exposure to other sick contacts, and travel in the recent past. 

Past Medical History:

• Medical problem list: Migraines until high school, Sinusitis, and Fibromyalgia, the last two years
• Preventative care: Fully vaccinated. The last Pneumococcal shot was given on April 20
• Surgeries: Endoscopic Sinus Surgery (2005) and Cognitive-Behavioral Therapy (1999)

• Hospitalizations: None
• CT Scan: Imaging test 2 months ago. Infection in the sinuses was reported.
• LMP, pregnancy status, menopause, etc. for women: Menopause since last year.

Allergies:

No known drug allergies. Food allergies: Gluten or Dairy (fatigue), sensitive to indoor allergens

Medications:

• Mucinex 15ml 2-3 times every day.
• Ibuprofen 15ml HS

Family History:

• Father, age 55, Asthma, Allergies
• Mother, age 50, Hypothyroidism
• Sister 28yo, Anxiety disorder
• Paternal Grandfather, Arthritis, age 70
• Paternal Grandmother, Asthma, age 78

Social History:

The patient denies smoking or taking cigarettes and takes beer twice a week. Married, is employed in creative arts, and paints as a hobby.

Other: N/A

ROS

General: Denies weight change or fatigue.

Eyes: Denies change of vision, pains, erythema, or too many tears. Denies blurred vision, double vision, or blindness. Ears/Nose/Throat/Mouth: Denies hearing problems, ear infections, and earaches. No sinus pain or nosebleeds. Minor sore throat and hoarseness of voice. No bleeding gums, dentures, sore tongue, or dry mouth. The most recent dental checkup was five months old.

Cardiovascular: Negative for any chest pain or palpitations.

Pulmonary: Negative for non-productive cough. Denies coughing up blood, shortness of breath, wheezing, or pleuritic pain.

Neurological: Experienced headache, particularly around the forehead. Reports dizziness, focal numbness/weakness, nausea, or vomiting.

Lymphatic: Denies swollen lymph nodes in the neck.

Allergy/Immunology: Seasonal or environmental allergies with chronic sinus infections.

Objective

Vital Signs: 

HR-80

BP-120/80

Temp-99.5

RR-16

SpO2- 98%

Pain level- 6 /10

Ht: 5 feet 6 in

Wt:150

BMI-24.2 (within normal range)

Labs, radiology, or other pertinent studies: Imaging tests, CT scans, or MRI

Physical Exam

General Appearance: Mild distress due to continuous body aches.

Head: Headache behind the eyes. Reports dizziness and tingling of limbs.

Eyes: Denies double or blurred vision.

ENT, Mouth: No hearing changes, earaches, or infection. No sinus pain or nosebleeds. mild sore throat and a hoarse voice. No bleeding gums, dentures, a sore tongue, or a dry mouth. The last dental exam was 4 months ago.

Breast: Mammogram reports no abnormality.

Cardiovascular/Peripheral Vascular: Reports no chest pain or palpitations.

Musculoskeletal: Reports no muscle weakness.

Integumentary: No blisters or blotches on the skin are observed

Allergic/Immunologic: Seasonal allergies. Exposure to smoke causes breathing difficulty.

Other: N/A

Assessment

Differentials

1. Sinusitis: Sinus inflammation that may lead to such symptoms as headache, body aches, and congestion. It can usually be accompanied by facial pains or pressures and can be due to a viral or bacterial infection (Ebell et al., 2019)
2. Common Cold: Headache, body aches, and congestion may be a result of a viral infection. It is normally accompanied by other symptoms such as a sore throat, cough, and sneezing.
3. Influenza (flu): A viral infection may have similar symptoms, which include headache, body aches, and congestion. It is commonly linked to high fever, fatigue, and respiratory symptoms.

Diagnosis: Sinusitis

Plan

Diagnostics: Symptom, length, and past history of sinusitis. Physical examination- tested the nose passages, sinuses, and throat for inflammation and infection. Imaging tests- CT scan or MRI.

Treatment: Nasealine nasal irrigation and nasal decongestants should be used twice a day to relieve the symptoms. Nasal Steroid sprays and Amoxicillin 500mg (3 times a day) can help decrease the inflammation and facilitate the sinus drainage and allergy treatment.

Follow-up: The physician should arrange a follow-up visit after two weeks to evaluate the response to the treatment and to change the management plan in case of need.