SOAP Note

Donald Davis

10/15/2017

S. Addie Adler a 53 year old white female presents in the clinic today with complaints of “feeling like my
head is going to explode.” Pt reports that she has been having this problem for two weeks that has
progressively gotten worse over this period of time. Pt reports that has an achy pressure in her head just
above and below her eyes. Pt denies any vision problems, itching, headache, hearing problems, or sore
throat. Pt does report that she has had a runny nose with drainage being clear at the beginning and now
turning a yellowish green color today. Pt does also have a dry unproductive cough and dry mouth. Pt
denies any other breathing problems except for the cough. Pt reports that she has taken Mucinex over
the last two weeks with no relief. Pt does also report that she has felt fatigued and has slight trouble
sleeping. Pt has not seen another healthcare provider for this problem.

Review of Symptoms

Constitution: Pt does have a fever, fatigue, and problems sleeping due to cough. Pt also has increased
pressure in frontal and maxillary sinuses.

EENT: Pt has no vision, throat, or ear problems. Pt does have yellow green rhinorrhea.

Cardiovascular: Pt does not have any cardiovascular symptoms

Respiratory: Pt has a dry unproductive cough.

GI/GU: Pt has no symptoms related to GI/GU

MSK: Pt has no symptoms related to MSK

Neurological: Pt has no neurological symptoms

Endocrine: Pt has no endocrine symptoms

Pmhx.

Pt has a mucus retaining cyst in maxillary. Pt has also had sinusitis in the past treated with antibiotics.

Family Hx

Pt’s mother died of breast cx at 63 and father died of MI at 65

Social Hx

Pt is a paralegal in a law office. She is not married walks in the evening for exercise and is a non-smoker
and non-drinker.

O. Vital signs BP 110/65 HR 62 RR 20 Temp 101.6

CN 1- Pt unable to smell/ Decreased patency likely cause

Transillumination of frontal and maxillary sinuses: No light able to seen on either exam

Palpation: Pt had pain in both frontal and maxillary sinuses with palpation

Lung exam: Pt’s lungs clear with auscultation

Nasal exam with otoscope: Pts nasal passages were red and swollen

Oral exam: Redness and swelling in oropharynx

Lymph node exam: negative for swelling

A. 1. Bacterial Sinusitis

2. Viral Sinusitis

3. Allergic rhinitis

P. Eval and treat with cervical adjusting, lymph massage, sinus adjustment with activator. Recheck in
two days.