Complete Notes and SOAP notes

Sinusitis

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HPI

*** is a healthy 39 yo (Fe)male with frequent sinus infections, who presents with 11 days of sick symptoms that she describes as a “head cold” that has improved, but resolved into her typical sinus pain and pressure symptoms. She has been taking pseudoephedrine without improvement. She has had two negative COVID-19 tests. She is requesting antibiotics.

History, meds, allergies, etc.

Med Hx: ***

*** smoker

Allergies: ***

Medications: ***

No recent antibiotic use.

ROS:

GENERAL: Denies fever, chills, night sweats, poor appetite.

EYES: Denies visual changes.

HENT: Complains of sinus pain and pressure. She states that her nares are partially patent with congestion. Denies sore throat, hearing changes.

RESP: Denies shortness of breath, cough.

CV: Denies chest pain, palpitations, leg swelling.

GI: Denies nausea, vomiting, diarrhea, abdominal pain.

GU: Denies dysuria, burning, urgency, and frequency

MSK: Denies swelling, joint pain, or stiffness.

NEURO: Complains of headache. Denies weakness, numbness or tingling.

DERM: Denies rashes.

All other systems were reviewed and are negative.

PE:

Exam was performed during video visit by direct visualization and questioning.

General: well-developed, no acute distress.

Eyes: sclera white. No gross vision problems noted

HENT: normal hearing, external ears appear normal

Resp: Spoke in full sentences, no labored breathing or wheezing heard

NS: A&O x 3

Skin: No visible rashes

Psych: Mood and affect WNL

Assessment

ICD-10 Codes

ICD-10 Code J01.00 Acute maxillary sinusitis, unspecified
ICD-10 Code J01.10 Acute frontal sinusitis, unspecified
ICD-10 Code J01.90 Acute pansinusitis or Acute sinusitis, unspecified

Assessment: there is no clinical evidence of meningitis, orbital cellulitis, tumor, or trigeminal neuralgia.

Plan

Get plenty of sleep. Stay hydrated. RTC if symptoms do not begin to improve within three days of initiating ABX or if fevers develop.

Medications

Amoxicillin-Clavulanate 875/125mg oral tablet

Take one tab oral two times a day for 7 days. May stop after 5 days if symptoms are gone.

SIG

14 tablets

DISPENSE

Amoxicillin-Clavulanate 500/125mg oral tablet

Take one tab oral three times a day for 7 days. May stop after 5 days if symptoms are gone.

SIG

30 tablets

DISPENSE

Augmentin prescription sent to pharmacy.
Also consider a medrol pack.
Consider referral to ENT if frequent Sinus infections
Advised to increase fluid intake, sinus rinses, saline drops, drink warm drinks w/honey, rest, use OTC cough/cold medicines.
RTC in couple of days, sooner if not better.
ER precautions discussed.

Advised to keep up to date w/immunizations.'

Add children's weight based dosing?

STI Screening

ASSESSMENT

*** yo Male/Female presents for an STI screen without symptoms. They have no current or recent fevers or illness and have a recent HIV screen, but can't recall when, and therefore declines an HIV screen.
***Always uses condoms.
***Denies ever having had any vesicular or crusting lesions in the genitals or genital area.

PLAN

Urine sent for G/C screening. Blood sent for RPR test.
Return in 2-4 days for results.
Return for additional screenings periodically.
Return for diagnostic screenings if you develop any lesions or suspicious symptoms in the genital, rectal, or oral areas.
Rectal swab not performed as patient
*** denies receptive anal intercourse
*** has no rectal discharge
Oral swab not performed as patient
*** denies oral sex
*** has no sore throat or oral discharge

Discussed Expedited Partner Therapy (EPT) and the patient ***.

SOAP: STI/Genital Sx

*** y/o (gender) comes in ℅ of (genital Sx) x () days. Pt is experiencing Sx of (discharge [color, odor, frequency, amount], rash/ lesions/ discoloration [describe], itching, pain [when urinating, light touch], urinary Sx [painful urination, split stream, blood in urine, frequency, etc], swelling. How many partners does the patient have? Last date of intercourse? Pt has/has not taken OTC medication.

AxO x 4 and vitals (). Assess color, swelling, pain, lesions, discoloration, lumps to the affected area. Take pictures with patient consent in chart of anything visible. Run UA as ordered.

SOAP: UTI/ Kidney Infection

*** y/o (gender) comes in ℅ of possible UTI x () days. Pt has been experiencing Sx of (Pain [numerical scale], burning upon urination, increased hesitancy/ frequency/ urgency when urinating, unusual odor to urine, blood in urine, abdominal pain [cramping or sharp], fever, chills, lower back pain [check CVA tenderness]. Pt has had x amount of UTI’s in the past or recently. Pt (is/isnt) sexually active. Pt has been taking (insert medications).

AxO x 4…(insert vitals).. CVA tenderness check. Abdomen is (soft, non-distended, boardlike, distended). Pt report (pain [sharp, tender, etc], no pain) when palpating the abdomen. Pt bowel sounds (active, underactive, overactive) in (RUQ, RLQ, LLQ, LUQ). UA and HCG (within child bearing age) result in PE tab. Urine sample color, opacity and debris. Heart RR, lungs {CTA/wheezing or crackles}.Uploaded to EKO.

SOAP: Eye Infection (Pink eye)

*** y/o (gender) comes in ℅ of (possible pink eye, eye discharge, stye, etc.) x () days. Pt has been experiencing Sx of (drainage [color?], redness in eye, scratchiness, watery eyes, swelling around eye, decreased vision [blurriness?], sensitivity to light, itching in eye [ask about any cough, nasal congestion, sinus pressure]). Does pt have allergies seasonally? Does patient wear contacts or correctional lenses? Pt has been taking (insert medications).

AxO x 4…(insert vitals).. Eye Assessment (redness, swelling, discharge, fore/ abrasion on/in eye, PERRL). Check EOM (painful?). Lightly palpated over upper eyelids while pt eyes are closed and states (pain, no pain). Extraocular movements (intact or not intact [pain when moving eyes up, down, left, right]) Visual acuity test results in PE tab. Picture of eye(s) in PE tab. HRRR, lungs {CTA/wheezing or crackles}.Uploaded to EKO.

SOAP: Rash or Skin Condition

*** y/o (gender) comes in ℅ of rash [reaction, blistering, burn, redness]. Pt is experiencing Sx of (area of body affected [where it started; did it spread] raised rash, fluid filled pustules, warmth to touch, itchiness, burning, tingling sensation, swelling, redness, discharge [color or odor?], fever, chills, N/V/D). New lifestyle changes, diet, pets, environment (outside). Any allergies? Hx of reactions. Pt has been using (insert medications).

AxO x 4…(insert vitals).. Rash Description (warm to touch, drainage, redness, swelling). Picture of rash with ruler in PE tab (take pics of all sites of body affected with ruler. Label each picture with where on body and date). Length and width of affected area. HRRR, lungs {CTA/wheezing or crackles}. Uploaded to EKO.

SOAP: URI

*** y/o (gender) comes in ℅ of URI Sx x () days. Pt has been experiencing Sx of (cough [productive or non-productive], color phlegm (if applicable), sore throat, sinus pressure, headache, ear ache, wheezing, lightheadedness, SOB, chest pain [tightness], nasal drainage [color], fever, chills, night sweats, N/V/D). Hx of Asthma? Pt has been taking (insert medications).

AxO x 4…(insert vitals).. Sinus pressure location, throat (swollen [left or right tonsil], red, exudates, post-nasal drip), nose with firefly [redness, swelling, bleeding, septum is midline], ears (redness, swelling, TM intact, fluid or bubbles behind TM ), lymph nodes (swollen or tender), heart (regular rhythm), lungs (wheezing, crackling, clear bilaterally [upper and lower]).

SOAP: Ear Ache

*** y/o (gender) comes in ℅ of earache x () days. Pt has been experiencing Sx of (ear pain [numerical scale], sharp or dull pain, drainage [color], ringing in ears, tenderness on outside ear, decreased hearing, sinus pressure, nasal congestion/drainage). Has pt been swimming or on a airplane recently? Pt has been using (insert medications).

AxO x 4…(insert vitals).. Ear appearance on outside. Assess ear by firefly and describe inner ear and TM (redness on canal or around TM , swelling in canal, fluid in ear, ear wax impaction). Pain when assessing the ear with firefly? Picture of inner ear in PE tab with firefly when abnormal findings are noted.

SOAP: FLU

*** y/o (gender) comes in ℅ of possible flu x () days. Pt has been experiencing Sx of (fever [temp], chills and night sweats, muscle aches, fatigue, productive or non-productive cough [color phlegm], congestion [chest or head], headache, N/V/D, swollen lymph nodes, sore throat [pain 1-10], headache, SOB, chest pain[tightness], dehydrated [fluid intake]. Has pt received flu shot this year? Been around anyone with flu Sx? Pt has been taking (insert medications).

AxO x 4…(insert vitals).. Pt throat [redness, swelling, post nasal drip]. Mucous membranes [wet or dry]. Nostrils w/ firefly [inflamed, congestion]. Ears [redness, swelling, TM]. Lymph nodes [swollen or tender]. Heart [regular rhythm]. Lungs [wheezing, crackling, clear; bilaterally]. Rapid Flu test result in PE tab [if applicable].

SOAP: Sore Throat/ Strep

*** y/o (gender) comes in ℅ of sore throat x () days. Pt has been experiencing Sx of (sore throat [pain 1-10], cough or no cough, headaches, fever [temp], chills, night sweats, swollen throat or lymph nodes, nasal congestion/drainage, N/V/D). Pt has been taking (insert medications).

AxO x 4…(insert vitals).. Throat [swelling, redness, exudates]. Lymph nodes [swollen or tender]. Nasal [inflammation, congestion]. Heart [regular rhythm]. Lungs [wheezing, crackling, clear]. Rapid strep test result in PE tab [if applicable]. Picture of throat if abnormal.

SOAP: Musculoskeletal (Back pain)

*** y/o (gender) comes in ℅ of (back ache, poss, broken bone, sprain, etc). Time and date of occurrence [how it happened]. Pt has been experiencing Sx of (back pain [1-10, sharp, shooting, radiating, dull], ROM limitations, discoloration, swelling, tingling/numbness, muscle spasms). What makes it worse [sitting, lying down, walking,etc..]. What makes the pain better [ice, rest, sleep, lying down, elevated, OTC meds]. Pt has been using (insert medications).

AxO x 4…(insert vitals).. Pt states of CC in clinic [visible discoloration, abnormalities in bone structure, ROM exercises [assisted/non assisted], swelling, tenderness when palpated, spine midline [if cc is back related], neuro exam findings, capillary refill. Picture of affected area in PE tab. {if possible, measurements of affected area(s)}.

SOAP: Chest Pain/ SOB

*** y/o (gender) comes in ℅ of chest pain or SOB x () days/hours. Time of occurrence. Hx of cardiopulmonary disease/ conditions [patient and family]. Pt is experiencing Sx of (SOB, hyperventilation, chest pain [1-10 pain], tightness, heaviness, swelling in throat, fast pulse, slow pulse, fatigues, lightheadedness/dizziness, vision changes). Does pt have Hx of anxiety disorder? What medications has patient been using [OTC and Rx]?

AxO x 4 and eyes PERRLA. (insert vitals) Assessment of breathing pattern [ hyperventilation, gasping, difficulty, unequal shoulder rise]. Heart [regular rhythm, irregular]. Lungs [wheezing, crackling, clear]. Pulses [radial, brachial, carotid, bounding, feeble, medium]. Skin color [blue, pale, normal]. Capillary refill.

SOAP: Medication Refill

*** y/o (gender) pt here for rx refill of (medication/s names). Pt has been taking these medication for (time pt has taken medication for) with/ without any adverse effects.(Date medication last took?). Pt confirms/denies (list symptoms associated with medication ie bp med=changes in bp/if they monitor bp at home, pain med=pain scale/location of pain/any otcs used, respiratory inhaler=breathing problems/cough, etc etc). (If applicable) photo of med bottle/rx of previous med in chart

Pt A&Ox4, afebrile/febrile in clinic, HRRR, lungs CTA/wheezing or crackles. VS WNL/abnormal(report abnormal values to provider via PC and retake values 2x before consult). peripheral pulses present x4, cervical lymph nodes not swollen or TTP, sinus pressure noted on palpation but no pain reported per pt. No pain noted behind ears. No cough reported per pt. 2nd bp taken in consult=156/96 l arm and 150/100

POC per(provider name): f/u in (insert timeframe) to see if medication dosage is effective. Pt advised to monitor sx daily. Medications sent to pharmacy. F/u (date) . {If pt is given BP or diabetes medication, please send them home with log and explain how to use it. Also ask them to bring to every appt}.

SOAP: Head Injury, Concussion, TBI

*** y/o gender come in ℅ of (head ℅ here) x days. Pt reports they (did/did not) have and injury [ detail injury: time, date, place, object causing injury]. Pt does/does not have hx of head injuries [detail, Tx and year]. Pt did/did not LOC. Pt reports having sx of (pain [location and type of pain], swelling, blurry vision, dizziness, laceration/abrasion, bleeding, drainage from ear, mouth, nose [color and consistency], fainting, loss of balance, memory loss, mood change, difficulty concentrating, light sensitivity). Pt has been using (medication).

AxO x 4 (ask simple questions [time, place, year, name, current president, color of common object [banana, grass, etc] did they have difficulty answering these questions. Asses head for swelling, lacerations, abrasions, discoloration, etc.. Eye exam [snellen chart, extraocular movements, PERRL?,]. Sensation to light touch intact or not intact [lightly touch different body parts and ask pt to let nurse know if they can feel it]. Facial expressions equal/unequal [ pt able to puff out cheeks, raise eyebrows, squint eyes] Gross hearing intact/ not intact [ have pt close eyes and rub your fingers next to each ear]. Shoulder resistance intact and equal [ place hands on top of shoulders with resistance and ask pt to shrug shoulders]. Tongue is/ is not midline when sticking out. Finger to nose test [ difficult for patient?]. Romberg test [detail if pt had difficulty performing standing up eyes closed, feet together, watch for swaying or imbalance. While in position briskly tap pt arms downward to see if they hold position]. If dizziness if Sx check for nystagmus [ have pt look horizontally and vertically]. Take photos of anything visual.

SOAP: Diabetes

Diabetes Soap Note
*** y/o (gender) pt here for diabetic care and management. Pt has been dx with diabetes {type 1, 2, pre-diabetic} for (x) years/months. pt has been managing diabetes with (diet, medications, exercise - list all meds in med/allergy tab). Pt {is/is not} insulin dependent. Pt has been taking medication for (time pt has taken medication for) with/ without any adverse effects. (Date medication last took?). Pt confirms/denies (list symptoms associated with medication ie BP med=changes in bp/if they monitor bp at home, pain med=pain scale/location of pain/any otcs used, respiratory inhaler=breathing problems/cough, etc etc). (If applicable) photo of med bottle/rx of previous med in chart
Pt states he {is/is not} experiencing any sx or problems at this time. Pt {does/does not} take blood sugar on a regular schedule (upload patients log into docs). Pt needs refill of (strips, lancets for (insert type of glucometer pt has) or medications (listed in med hx). Pts last blood work done (date with values if available - A1C, LDL, Ratio, thyroid function, fasting lipid profile, liver function)

A&O x4 VS {WNL/abnormal(report abnormal values to provider via PC and retake values 2x before consult and add values here for each)}. afebrile/febrile in clinic, HRRR, lungs {CTA/wheezing or crackles}.Uploaded to EKO. (As needed; Skin examination - acanthosis, injection sites, neuropathy)

(ask provider if they would like a FSBG via practice chat before they do the visit so they have the results-
{verbal/written} FSBG Results: XXX {fasting/Not fasting}

Provider:
POC:
F/U:

Obesity / Weight Loss

SOAP: Weight Loss

Weight Loss Counseling and Note

Discussed lifestyle changes to include discussions of proper eating habits, healthful snacking, etc.
We discussed Intermittent fasting, fad diets, and using your willpower at the supermarket, not in the kitchen. We discussed quality of food, macronutrients, and portion size. We discussed reduction in alcohol consumption, and carbohydrate consumption in general.

Additionally, we discussed prescription stimulants for weight loss and the GLP-1 agonists. I explained the hoops he has to jump through to get the GLP-1s covered by insurance and that without comorbidities, he is not likely to get them covered.

Additional lifestyle recommendations:

Reduce stress. Be aware of how stress affects food choices.
Try to handle emotions in a healthy way. Exercise can help relieve stress and strong emotions.
Stressed the importance of sleep and rest
Stressed the importance of movement, aerobic exercise, and being more active. Strategies for finding ways to move when it’s difficult to exercise.
Eat a variety of nutrient-dense foods from the basic food groups and limit your intake of saturated and trans fats, added sugars, salt, and alcohol.
Be physically active for at least 30 minutes on most or all days of the week. This level of exercise helps reduce your risk for chronic diseases such as diabetes. Set goals for moderate-intensity physical activities, such as walking at a brisk pace, and chart your progress as you increase your activity level.
Be physically active for 60 to 90 minutes a day if you are trying to lose weight or sustain weight loss. Chart your progress as you increase your activity level.
Take stairs instead of elevators, park further from entrances, walk instead of watching TV after dinner. Make sure you are in locations that are both safe and well-lit when engaging in these activities.
Keep a food diary. Write down all of the food you eat in a day, what time you eat, and your feelings at the time. Look at your diary to find ways to improve your eating habits.
Dish up smaller amounts of foods from a variety of food groups. Measure your portions against the serving size listed on food packaging for a few days so you know how much you are eating. You may want to consider the new Dietary Guidelines for Americans 2005, which you can find online at www.healthierus.gov/dietaryguidelines.
At restaurants, eat only half of your meal and take the rest home.

Counseling Obesity

Patient counseled on obesity and the need to decrease animal fats and carbohydrates in diet. The patient is encouraged to increase fresh fruits and vegetables and water intake, and develop cardiovascular exercise program consistent with JNC seven guidelines for cardiovascular fitness to encourage weight loss and avoid other health problems secondary to obesity.

--Specific Recommendations

1. Lose weight.
2. Cut back on calories.
3. Choose healthier fats.
4. Limit how much alcohol you drink.
5. Exercise regularly.

Approximately 15 minutes spent counseling patient on this topic.

Counseling Weight loss Yesim

*Low carb and fat diet:
1. low carb diet: decrease bread, pasta, tortilla, corn, potato, sweets or ice cream
2. Low fat diet: decrease red meat ( lamp, beef, pork) increase white meat (chicken, turkey and fish). when eating turkey or chicken remove the skin.
3. No frying. Baking, BBQ or boiling the food is OK.
4. Eat lots of vegetable especially dark green leafed veggies.

* Decrease your daily calorie intake to 1400 calorie a day. First please calculate how much normally you consume daily. If your daily intake is more then 1400 calorie a day, every week, please decrease your daily calorie intake 200 calorie every week or every other week till you are down to 1400 calorie a day when you are exercising, you may eat extra 100 calorie that day.

* please start 16 hours fasting once a week. Usually starting your day with late breakfast around 10 am will help you to tolerate 8 hours eating period. You can eat till 6 pm that day and you can eat whatever you want to eat in this 8 hours time period. After 6pm you need to stop eating till next day 10 am ( for 16 hours fasting). Make sure you drinks lots of water.

* Physical inactivity leads to at least 250,000 deaths annually in the United States, and more than one half of Americans fail to meet recommended physical activity levels. Regular physical activity decreases total mortality rates as well as the incidence and mortality of cardiovascular disease, diabetes, and some cancers. Physical activity improves mental health and control of diabetes, hypertension, and lipid levels; prevents osteoporosis; and, especially in older patients, sustains mobility, reduces disability, and decreases the risk of falls.
The Centers for Disease Control and Prevention, American College of Sports Medicine, U.S. Surgeon General, and American College of Preventive Medicine recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (i.e., walking fast [3 to 4 miles per hour] or the equivalent) on five or more days of the week. The following are key principles for physical activity: (1) the more activity the better, (2) accumulated time is more important than intensity, (3) activity can be accumulated in 10-minute increments, and (4) lifestyle activities (e.g., substituting walking or biking for short car rides, using a push rather than a riding lawn mower) are more likely to be sustained than structured activities (e.g., exercising at a gym).
patient counseled more than 10 minutes for exercise.

Notes: