This week focused on current treatment strategies for common eyes, ears, nose, and throat disorders, including medications and nonpharmacological management.
Now it’s time to synthesize the subjective and objective information obtained in the visit to formulate differential diagnoses and a final diagnosis.
See the SOAP note template on Lauren Mesa.
Week 3 Case Study Lauren Mesa SOAP Note Template (SHOWN BELOW)
Review the pertinent subjective and objective findings for Ms. Mesa and synthesize the data to formulate a comprehensive list of 3 differential diagnoses. Include your rationale for ruling each differential in or out and justify your clinical decision-making by citing and referencing evidence-based resources. Conclude the assignment with your final diagnosis and ICD 10 code.
SOAP Note Template
Use for both Comprehensive Physical Exam & Focused Exam
Only difference is Focused Exam requires only “pertinent” ROS & Exam.
Subjective
Patient’s Initials: LM
Gender: Female
DOB: 2-12-1973
Age: 48
Ethnicity: Hispanic
CC: sinus pressure
HPI: Patient presents to the clinic complaining of onset of allergy symptoms a couple months ago. Over the past couple weeks, she has felt progressively worse, c/o severe sinus headache pressure over her eyes and a constant sore/burning throat (3/10 intensity). She has felt feverish the past week but doesn’t have a working thermometer. She feels mildly better after taking 1000mg of acetaminophen. She has seasonal allergies but reports they have been unusually severe this year despite taking her allergy meds. Her eyes and nasal passages itch and burn. She c/o severe nasal congestion and her nasal discharge is thick and yellow-green. She c/o bilateral cheek pain.
She expresses concern she may be getting the flu since she received a flu shot at work 2 weeks ago and worries the shot may have exposed her to the flu virus.
PMH: Infectious mono age 18, Seasonal allergies
Surgical History: None
FH:
Mother: HTN, T2DM, asthma, hyperlipidemia
Father: deceased age 75 CVA; had HTN, T2DM, hyperlipidemia
MGM: deceased age 82 Heart Failure, had HTN, T2DM,
MGF: deceased age 78 MI, had HTN, CABG x 2, hyperlipidemia
Sisters x 3: all with HTN, obesity, seasonal allergies
Social History:
Single, works as English teacher at high school level, lives alone in condo with 3 cats, drinks 2-3 glasses wine/week, no tobacco or illicit drug use, no vaping, sexually active, eats regular diet; tries to avoid sweets, walks 3 times/week for 30 minutes
Allergies: PCN (rash)
Current Medications: Allegra 180mg QD
Immunizations: Tdap: 2018, Flu: 2020
- Health Maintenance: Pap smear: 5/2020- normal
- Mammogram 5/2020- normal
- Immunizations: Tdap: 2018, Flu: 2020
ROS
General: c/o increased fatigue past week and going to bed early
(HEENT):
Eyes: see HPI; eyes feel dry but sometimes will tear excessively
Ears: c/o ear congestion and popping at times; denies d/c
Nose: see HPI
Throat: see HPI
Neck: denies enlarged or painful lymph nodes
Respiratory: c/o cough but attributes to thick post nasal drainage. Denies dyspnea
Cardiovascular: denies chest pain, palpitations, orthopnea
Skin: denies new dry skin lesions
MSK: denies myalgias
Objective
Vital Signs:
Temp: 100.6
BP:110/68
Pulse: 90
RR: 18
Pulse ox: 96
Pain: n/a
Height: 65″ (Percentile for peds)
Weight: 145# (Percentile for peds)
BMI: 24.1
Physical exam
General: Well developed, well -nourished female in no acute distress.
HEENT
Head: normocephalic
Eyes: symmetrical, conjunctiva pink, sclera injected bilaterally, no discharge noted, allergic shiners noted bilat
Ears: Pinna, tragus, lobe free of lesions and nontender, TM intact bilat -pearly gray; unable to visualize cone of light reflex bilat
Nose: septum midline, turbinates 3-4+, erythematous, moderate amount viscous pale green d/c noted bilat. Exquisitely tender to palpation over bilateral maxillary sinuses. Mild tender over bilat frontal sinuses
Throat: lips dry, good dentition, gingiva, and buccal mucosa pink and moist, pharynx mildly erythematous, tonsils 2+ bilat, no exudate
Neck/Lymph: trachea midline, mild bilat anterior cervical LAN
Chest/Respiratory: Normal A/P diameter, Lungs CTA without adventitious sounds
Cardiovascular: No lifts, heaves, S1 S2, no murmurs
Skin: warm, dry, appropriate for ethnicity
Laboratory data: rapid strep negative
Imaging results: none
Other diagnostic data: none
Recognition and review of the documentation of other clinicians: none
Assessment
Final Diagnosis/ICD 10:
Rationale how arrived at this final diagnosis (extract subj/obj data) and EBP support.
Differential diagnoses
| Differential Diagnoses | How was this diagnosis ruled out? Synthesize the subjective & objective data and provide EBP support |
| 1.) | |
| 2.) | |
| 3.) |
