Revised sp2023

SOAP Note #1 – NURS 7550 Geri

Student Name: Mary Parker Davidson

Population (Geri/Adult/WH/Peds): Geri

Clinical Location and Preceptor: Merit Health Richland (Greg Ross, FNP and Nell Hunter, FNP)

Date of Patient Encounter: 9/21/23 Patient Identifier (Initials/number): RC 4872

Patient age/DOB: 69, 7/14/1954 Ethnicity and Gender: Caucasian, Male

I. Chief Complaint: “I have terrible sinus drainage and congestion and my head is pounding”

II. History of Present Illness:

Patient is a 69 year old male who presents to the clinic with sinus drainage and congestion. Patient stated he
had a mild cold 2 weeks ago, but his current symptoms started a week and a half ago. Patient states his
symptoms are continuous and that he also has a headache that is dull and constant, and he rated his pain at a 6.
He said nothing has aggravated or relieved his symptoms, and that he has been taking 4 ibuprofen a day to
help with the headache, but he doesn’t think it has really helped much.

III. Past Medical History:

1. Childhood illnesses & developmental milestones
a. Patient denies chicken pox, rubella, mumps, whooping cough, rheumatic fever, scarlet fever,
polio in childhood and met all developmental milestones
2. Chronic Illnesses
a. Hypertension – diagnosed in 2010, well controlled with medication and lifestyle
modifications
b. Hyperlipidemia – diagnosed in 2010, well controlled with medication and lifestyle
modifications
3. Prior Illnesses and Injuries (accidents and hospitalizations)
a. Patient reports being hospitalized for hernia repair surgery in 2005 at UMMC in Jackson, MS
b. Patient denies any prior injuries, illnesses, or accidents.
4. Past Surgical History
a. Patient reports having an umbilical hernia repair surgery in 2005 at UMMC in Jackson, MS.
No complications from surgery.

IV. Current Health Status:

1. Health Status (including potential current stress)
a. Patients reports her health status as “pretty good.” Patient reports having mild stress levels
related to his worrying about his children who live far away.
2. Allergies
a. Patient reports no known food allergies.
b. Patient reports being allergic to Penicillin and getting a “itchy rash” if he takes it.
3. Medications: this includes over the counter and complimentary medications/treatments
a. Rosuvastatin – 20 mg, PO, daily, started in 2010 for Hyperlipidemia prescribed by Greg
Ross, NP
b. Losartan/Hydrochlorothiazide – 50 mg/12.5mg, PO, daily, started in 2010 for Hypertension
prescribed by Greg Ross, NP
c. Diltiazem – 180mg ER, PO, daily, started in 2010 for Hypertension prescribed by Greg Ross,
NP
Revised sp2023
4. Tobacco Use
a. Patient denies use of tobacco, cigarettes, dip, vaping, e-cigarettes, or exposure to secondhand
smoke
5. Alcohol Use
a. Patient reports no current or previous alcohol use.
6. Illegal/Recreational Drug Use
a. Patient denies illegal or recreational drug use in the past or present
7. Environmental hazards
a. Patient denies any known environmental hazards such as sun exposure, chemical exposure, or
radiation at home or work
8. Safety measures
a. Patient states he takes employs safety measures on a regular basis such as uses a seat belt, has
smoke detectors in the home, wears a bike helmet, does not own firearms, does not use her
cell phone while driving.
9. Exercise & leisure
a. Patient reports playing pickle ball for 1-2 hours, 3-4 times a week, for the last 6 months.
Patient also reports going on walks 5-7 times a week with his wife.
10. Sleep
a. Patient reports having a normal sleep routine. Patient reports going to bed and wakes up at
roughly the same time every day and gets 7-8 hours of sleep on average. Patient does not
report taking naps. Patient denies having trouble falling or staying asleep and does not wake
in the night. Patient denies use of sleep aids or medications.
11. Diet
a. Patient reports having a mostly healthy diet. Patient reports trying to drink 100 oz of water a
day. Patient reports drinking 1 cup of coffee each morning. 24 hr recall: 3 scrambled eggs and
wheat toast with jelly for breakfast, an apple as a snack, and turkey club with a salad for
lunch, homemade burgers with sweet potato fries for dinner.
12. Immunizations
a. Patient states he is unsure of last tetanus booster
b. Patient reports polio, measles, rubella, mumps, and HPV vaccinations are up to date
i. Patient unsure of number of MMR immunizations or the age of her first MMR
immunization
c. Patient reports he does get the flu shot yearly and received 2023 flu shot during his
appointment today
d. Patient states he has received the Hepatitis B vaccine
e. Patient states he has not gotten the COVID-19 or pneumococcal vaccines
13. Preventive Screening tests
a. Patient reports going to the dentist in July 2023: patient reports he received a teeth cleaning
and had no cavities or other tooth problems found
b. Patient reports he has not has his vision tested but uses reading glasses.

V. Family History- should go back at least 3 generations (patient, parents, and grandparents):
 Maternal Grandfather
o Died at age 80 from a heart attack, had HTN and HLD
 Maternal Grandmother
o Died at age 86, overweight, had dementia
 Mother
o Living, age 92, has mild dementia
 Paternal Grandmother
o Father was estranged form his parents so patient does not know
 Paternal Grandfather
o Father was estranged form his parents so patient does not know
 Father
o Died at age 88 from returning prostate cancer
 Patient
Revised sp2023
o Age 69, HTN and HLD

 Family Risk Factor Analysis: patient is at risk for cardiovascular problems such as hypertension and
hyperlipidemia.. Patient will need to continue to go to her appointments with her PCP to monitor her BP
and her cholesterol. Patient will also need to continue practicing methods to reduce risk factors for HTN
and HLD, such as regular exercise, healthy diet, not smoking, and maintaining a healthy weight. Patient is
also at risk for prostate cancer and will continue to avoid risk factors for prostate cancer such as smoking,
obesity, alcohol consumption, and physical inactivity. Patient also at risk for dementia. Patient will need
to continue to consult with his provider if her or her family members notice any dementia symptoms, such
as forgetfulness, confusion, or repetitive questioning.

VI. Social History:

1. Education
i. Patient reports having a Master’s in Hospital Administration
2. Occupation
i. Patient reports being retired, but worked in hospital administration for 40 years.
3. Marital status
i. Patient reports being married
4. Children/dependents
i. Patient reports having 2 children (40 and 43) who both live out of state
5. Type of housing & who the patient lives with
i. Patient reports living in a house with his wife out in the country
6. Financial resources/insurance
i. Patient states he is financially stable and has health insurance
7. Religion/beliefs
i. Patient states he is a Christian
8. Social involvement
i. Patient states he and his wife play pickle ball with their friends during the week, as well as being
involved in their church
9. Travel
i. Patient reports he and his wife travel frequently, with their last trip being an Alaskan cruise a
month ago.

VII. Review of Systems:

General/Constitutional: denies weight change, weakness, fatigue, night sweats, anorexia,

Malaise. Patient reports mild fever for the last few days.
Integumentary: denies color changes, itching, bruising, infections, rashes, sores, changes in moles,
changes in hair or nails, sensitivities
Eyes: denies vision changes use of glasses/contact lenses, eye pain, eye or eyelid redness, excessive
tearing, double vision, floaters, loss of any visual fields,
history of glaucoma or cataracts
Ears, nose, and throat/mouth:
i. Ears: denies hearing loss, change in hearing, ringing in ears, pain in ears, drainage from ears
ii. Nose: denies, nosebleeds, nasal pain, change in ability to smell, sneezing. Patient reports nasal
stuffiness, sinus pain, sinus congestion, nasal discharge (green/yellow), and post-nasal drip.
iii. Throat/mouth: denies mouth soreness, mouth dryness, ulcers, sore tongue, bleeding gums, pyorrhea,
teeth issues (caries, abscesses, extractions, crowns, caps, or dentures), sore throat, hoarseness
Neck: denies lumps, swollen lymph nodes or glands, goiter, pain, change in mobility/ROM
Breasts: denies lumps, pain, nipple discharge, reports administering self-examinations
Respiratory: denies acute or chronic cough, trouble breathing, wheezing, coughing up blood, history of
exposure to TB, recurrent pneumonia, environmental exposure
Cardiovascular: denies chest pain, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, lower extremity
edema, palpitations, syncope or near syncope, pain in posterior calves with walking, varicosities,
thrombophlebitis
Revised sp2023
Gastrointestinal: Denies trouble swallowing, pain with swallowing, nausea, vomiting, vomiting blood, food
intolerance, indigestion, change in appetite, sensation of filling up earlier than usual, changes in bowel
pattern, rectal bleeding, passing black tarry stools, constipation, diarrhea, abdominal pain, excessive belching
or passing of gas, hemorrhoids, jaundice. Reports daily, formed bowel movements.
Genitourinary: Denies Blood in urine, pain on urination, increased frequency of urination, suprapubic pain,
pain in low back or sides, frequent urination at night, passing large volumes of urine on a frequent basis,
history of stones, inguinal pain, trouble initiating urinary stream, incontinence, or history of urinary tract
infections.
Musculoskeletal: denies joint pains or stiffness, arthritis, gout, backache, joint swelling or tenderness or
effusion, limitation of motion, weakness
Neurologic: denies fainting, blackouts, seizures, paralysis, local weakness, numbness, tingling, tremors,
memory changes, vertigo or dizziness, muscle atrophy. Patient reports a dull, persistence headache that is
not like his normal tension headaches he gets.
Psychiatric: Denies anxiety, nightmares, nervousness, irritability, depression, insomnia, hypersomnia,
phobias, tension, suicidal or homicidal ideations
Endocrine: denies any thyroid problems. Denies heat or cold intolerance, excessive sweating or flushing,
diabetes, excessive thirst or hunger, or urination
Hematologic/Lymphatic: denies anemia, easy bruising or bleeding, past transfusions,
Swollen lymph nodes in neck, axillae, epitrochlear areas, or inguinal area
Allergic/Immunologic: denies itchy watery eyes, hives, rhinorrhea, immunocompromise, frequent infections

VIII. Physical Examination:

General appearance: patient does not appear acutely ill, mildly overweight, appears stated age, well
groomed and dressed appropriately
Vital signs: ***
o BP: 119/78, HR: 70, RR: 15, Temp: 99.5 (Oral)
o Height: 511”, Weight: 190 lbs, BMI: 26.5 (overweight)
Skin: skin is warm and dry with appropriate coloring for ethnicity. No rashes, lesions, icterus, pallor,
edema or cyanosis.
HEENT:
o Head: skull normocephalic with no visible or palpable lesions, masses, or scarring. Scalp is clean
and without excess oil or parasites. Hair color and texture appropriate for ethnicity and is evenly
distributed. TMJ palpated and smooth, symmetric movement with full ROM found with no
clicking or patient reported pain during movement.
o Eyes: Eyes symmetrical. Eyelids, eyelashes, and lacrimal glands normal in appearance without
redness, discharge, lesions, or swelling. Lids without ptosis or swelling. Sclerae white and
without icterus or muddy appearance. Conjunctiva pink. Cornea translucent and smooth. Irises
dark brown. PERRLA. Left and right direct light reflex intact. Left and right consensual light
reflex intact. Visual acuity 20/20 using Snellen chart. Negative nystagmus. Positive red-light
reflex. On fundoscopic exam: clear, pink optic disc with sharp margins. Retina is red/orange and
macula is dark with fovea centralis located at the center of the macula. Retinal vessels: arteries
appear bright red and veins appear slightly purple, AV ratio 2:3. No retinal lesions.
o Ears: Ears symmetrical. External auditory canal without tenderness, swelling, or excess cerumen.
Tympanic membranes pearly grey and translucent with cone of light present.
o Nose: Nose midline. Nares partially obstructed. Nasal mucosa moist with erythema and edema.
Septum midline. Turbinates not enlarged or reddened. Frontal or maxillary sinus tenderness
present upon palpation and percussion.
o Throat: Lips warm and dry. Teeth intact. Buccal mucosa, gingiva, hard and soft palate, and sub
glossal area pink and moist with no exudate or lesions. Mild breath odor. Tonsils present without
swelling or exudate. Mild posterior pharyngeal erythema with post nasap drip. Uvula midline.
Neck: Neck mobile. Thyroid palpable without hardness, nodules, masses or tenderness. Trachea midline
and without stridor. Carotid pulses audible upon auscultation and without bruits. No jugular venous
distention or hepatojugular reflux.
Nodes: No submandibular, submental, tonsillar, pre- and post-auricular, occipital, anterior and
Revised sp2023
posterior cervical triangles, supraclavicular, axillary, epitrochlear, or inguinal lymphadenopathy, swelling
or tenderness.
Respiratory and Thorax/Breast: Chest wall is symmetrical with no deformities and without tenderness.
Patient is without increased work of breathing and accessory muscle use. AP ratio 2:1. No fremitus upon
palpation. Resonance present upon percussion. Breath sounds clear in all lobes anteriorly, posteriorly,
and laterally and without crackles, wheezes, rhonchi, or rubs.
Cardiovascular & Peripheral Pulses: Chest has no abnormal outward pulsations and no lifts, leaves,
shock or murmurs upon palpation. PMI not visible and palpated at the 5th intercostal space at the
midclavicular line, and not abnormally sustained. Upon auscultation, regular heart rate and rhythm noted.
S1 and S2 heard. Aortic, pulmonic, Erb’s point, tricuspid and mitral areas auscultated and no murmurs,
gallops, rubs or clicks heard. Cap refill < 3 seconds in all four extremities. Carotid, brachial, radial,
femoral, popliteal, dorsalis pedis, posterior tibial pulses all 2+
Abdomen: Abdomen symmetrical and flat, with no scars, masses, lesions, or abnormal venous patterns.
Bowel sounds present and normoactive in all four quadrants. No bruits. On percussion, tympany over
stomach, epigastric area, and upper midline. Dullness over full bladder, left lower quadrant, and liver
(Liver size 8cm). Abdomen soft with no masses or hernias. No liver and spleen enlargement. No rebound
tenderness or guarding. No abdominal tenderness or pain reported.
Genitourinary: Vaginal exam not needed.
Rectal: Rectal exam not needed.
Musculoskeletal: Patient has erect posture and full ROM of spine present (flexion, extension, lateral
bending, and rotation). No scoliosis or tenderness. No CVA tenderness. Upper extremities symmetrical,
skin warm and dry. No lesions, rashes, tremors, or edema. Lower extremities symmetrical, skin warm and
dry. No lesions, rashes, tremors, or edema. Nails translucent, pink, and firm. No cyanosis or clubbing.
Full ROM present (flexion, extension, abduction, adduction, internal and external rotation where
appropriate) for all upper and lower extremity joints. No joint swelling, deformities, tenderness, warmth,
erythema, or effusions. Upper extremities muscle strength 5/5. Lower extremities muscle strength 5/5.
Grip strengths present and symmetrical.
Neurologic:
o Mental status: Patient alert and oriented with appropriate behavior to situation, attention,
concentration, language. Memory intact (3 words provided to patient at the beginning of
assessment, patient able to recall the 3 words at the end of the assessment). Abstract reasoning
intact (patient able to interpret proverb).
o Cranial Nerves:
o CN I intact: patient able to correctly describe odor of an alcohol swab.
o CN II intact: patient able to read with both eyes and each eye.
o CN II & III intact: PERRLA (pupils equally round and reactive to light and
accommodation).
o CN II, IV, & VI intact: EOM’s and corneal light reflex WDL.
o CN V intact: patient able to clench jaw, sensory function of face intact.
o CN V, VII, X, & XII intact: patient able to speak clearly and audibly. Patient able to taste
correctly.
o CN VII intact: patient able to smile, puff cheeks, shut eyes tight, and raise eyebrows.
o CN VIII intact: whisper test WDL
o CN IX & X intact: gag reflex present and able to swallow without difficulty.
o CN XI intact: patient able to shrug shoulders and turn head from side to side.
o CN XII intact: patient able to move tongue.
o Motor: Patient able to regular, toe, heel, and tandem walk appropriately. Balance intact. No
involuntary movements (fasciculations, tremor, chorea, or posturing). Limb tone without
spasticity, rigidity, cogwheeling, or flaccidity. No muscle contractures or tenderness.
o Sensory: Patient able to sense pain, pinprick, light touch, hard/soft, sharp/dull, and 2-point-
discrimination. Intact graphesthesia (identified numbers drawn in the palm) and stereognosis
(identified a paperclip and a coin).
o Cerebellar: Gait steady with appropriate arm swing. Patient able to complete finger finger-to-
nose, heel-to-shin, rapid alternating movements, and standing with feet together and eyes open.
Revised sp2023
o Posterior Column: Able to sense vibration. Negative Romberg.
o Reflexes: biceps, triceps, brachioradialis, patellar, Achilles, and plantar deep tendon reflexes 2+
Psychiatric: Appropriate mood and affect. Does not appear depressed. Normal attention and
conversation.
Hematologic/Immunologic: no bleeding or bruising

IX. Diagnostic Testing:

o None

X. Differential Diagnosis with ICD-10 codes: (with definition and rationales supporting and refuting for each)
o (ICD 10 CODE: J01.9) Viral Rhinosinusitis – Viral Rhinosinusitis is when a viral infection causes the
paranasal sinuses to become inflamed, which causes the retention of secretions and increased facial
pressure. Patient reported sinus congestion, headache, sinus drainage, purulent nasal discharge, and
sinus tenderness. Patient also reported that his symptoms started after having a cold and have been
consistent and lasted a week and a half (longer than 10 days without improvement), which is not
consistent with viral rhinosinusitis.
o (ICD 10 CODE: J30.9) Allergic Rhinitis – Allergic Rhinitis is an IgE mediated response after an
exposure to an allergen and consists of nasal mucosa inflammation, Symptoms include sneezing,
nasal congestion, nasal itching, clear rhinorrhea, itchy eyes, watery eyes, and eye redness. Patient
reported nasal congestion and nasal discharge, but the nasal discharge reported was purulent not clear.
Patient also did not report or show any eye itching, watering, or redness, or any nasal itching. Patient
also did not report seasonal allergies.
o (ICD 10 CODE: J32.9) Bacterial Rhinosinusitis – Bacterial Rhinosinusitis is when a bacterial
infection causes the paranasal sinuses to become inflamed, which causes the retention of secretions
and increased facial pressure. Bacterial rhinosinusitis often occurs after a viral infection. Patient
reported sinus congestion, headache, sinus drainage, purulent nasal discharge, and sinus tenderness.
Patient also reported that his symptoms started after having a cold and have been consistent and lasted
a week and a half (longer than 10 days without improvement), which is consistent with bacterial
rhinosinusitis.

XI. Definitive Diagnosis with ICD-10 code:

o J32.9: Bacterial Rhinosinusitis

XII. Chronic Health Problems with ICD code:

o I10.9: Essential Hypertension, unspecified
o E78.5: Hyperlipidemia

XIII. Plan: (acute and chronic illnesses)

Bacterial Rhinosinusitis
A. Treatment
 Pharmacological
o Doxycycline 100 mg PO BID for 7 days
o If causes GI upset patient can take with food or milk
o Make sure to finish entire dose of Doxycycline
o Avoid excess sun exposure, as Doxycycline causes photosensitivity
o RTC if no improvement in 72 hours or no resolution of symptoms after finishing course of
antibiotics
 Medication profile: Doxycycline
o MOA: inhibits bacterial protein synthesis by binding to the 30S ribosomal subunit, is
bacteriostatic
o Drug class: Tetracycline Antibiotics
o Indication: used to treat a broad range of infections that are caused by susceptible gram positive,
gram negative, anaerobic, or other bacteria
Revised sp2023
o Generic name: Doxycycline
o Brand names: Vibramycin-D, Efracea, Periostat
o Usual dosage for Sinusitis: 200mg/day PO divided q12-24h for 5-7 days
o Cost:
 Walgreens: $27.57 for 20 tablets ($1.38 each) (Doxycycline hyclate).
 Kroger: $13.06 for 20 tablets ($0.65 each) (Doxycycline hyclate).
 Walmart: $9.57 for 20 tablets ($0.48 each) (Doxycycline hyclate).
B. Education
 Patient educated that Bacterial Rhinosinusitis is when a bacterial infection causes the paranasal sinuses
to become inflamed, which causes the retention of secretions and increased facial pressure, and that
bacterial rhinosinusitis often occurs after a viral infection, such as a cold or flu. Patient also educated
on how Doxycycline works killing the bacteria by stopping protein synthesis needed for the bacteria to
survive. Patient told the side effects of Doxycycline are nausea, vomiting, diarrhea, headache,
abdominal pain, and photosensitivity.
C. Follow-up
 Patient told to RTC if no improvement in 72 hours or no resolution of symptoms after finishing course of
antibiotics. Patient also told to go to the emergency room if they develop severe watery stools or bloody
stools.
D. Referral or consultation
a. No referral or consultation needed at this time.
E. Health Maintenance and Health Promotion/ Lifestyle Management
a. Patient educated on lifestyle modifications to help alleviate/prevent Bacterial Rhinosinusitis such as
symptomatically treating viral infections with nasal saline irrigation, expectorants, and nasal
decongestants.

Hypertension (chronic)
F. Education
 Patient educated to continue practicing methods to reduce risk factors for HTN and HLD, such as
regular exercise, healthy diet, not smoking, and maintaining a healthy weight. Patient educated to
reduce sodium, alcohol, and caffeine intake. Patient also educated on how Hydrochlorothiazide works
by causing increased excretion of sodium and fluid to decrease blood pressure. Patient told the side
effects of Hydrochlorothiazide are dizziness, blurred vision, headache, increased urination, and muscle
cramps.
G. Follow-up
a. Patient told to return to the clinic in 3 weeks and to call if patient has side effects of medication that
worsen.
H. Referral or consultation
a. No referral or consultation needed at this time.
I. Health Maintenance and Health Promotion/ Lifestyle Management
a. Patient educated on lifestyle modifications to help decrease HTN such as maintaining a healthy weight,
exercising regularly, eating a healthy diet, reducing stress, reducing sodium in the diet, and limiting
alcohol. Patient encouraged to continue monitoring blood pressure at home regularly.

Hyperlipidemia (chronic)
J. Treatment
 Pharmacological
o Patient educated to continue taking his Lipitor as prescribed.
K. Education
 Patient educated how hyperlipidemia is when the levels of lipids in the blood are too high. Patient
educated how Lipitor is a HMG-CoA reductase inhibitor and works to decrease the amount of lipids in
the blood by slowing the production of cholesterol. In doing so, Lipitor aids in the prevention of
atherosclerosis. Patient educated to take her Lipitor at night, as the body produces the most cholesterol
at night.
L. Follow-up
a. Patient educated to continue coming to the clinic every 6 months to get lipids checked.
Revised sp2023
M. Referral or consultation
a. None needed at this time
N. Health Maintenance and Health Promotion/ Lifestyle Management)
a. Patient educated on lifestyle modifications to help prevent hyperlipidemia such as limiting foods high in
cholesterol and saturated fats, exercising regularly, having a healthy diet, and maintaining a healthy
weight.
Revised sp2023

References

Doxycycline hyclate. GoodRx. (n.d.). https://www.goodrx.com/doxycycline-hyclate