Summarize and discuss the clinical characteristics and identify the appropriate laboratory, imaging, and other diagnostic and screening tools that apply to this condition or disorder. Explain why you selected these tests or tools as being appropriate to this process. Support your summary and recommended plan with a minimum of two APRN-approved scholarly resources.

Summarize and discuss the clinical characteristics and identify the appropriate laboratory, imaging, and other diagnostic and screening tools that apply to this condition or disorder. Explain why you selected these tests or tools as being appropriate to this process. Support your summary and recommended plan with a minimum of two APRN-approved scholarly resources.

Summarize and discuss the clinical characteristics and identify the appropriate laboratory, imaging, and other diagnostic and screening tools that apply to this condition or disorder. Explain why you selected these tests or tools as being appropriate to this process. Support your summary and recommended plan with a minimum of two APRN-approved scholarly resources.

SOAP Note: Sinusitis

SOAP Note

Subjective

Patient:  JR, 10 years, Male

Chief Complaint: “I have a stubborn cough.”

History of Present Illness:  10-year-old JR is brought to the clinic by his mother, who complains that he has had a persistent cough over the past two weeks. The cough started with a cold that he probably picked from other students in school. The cough is non-productive. JR notes that he has a runny nose with a green-yellowish nasal drip. The mother notes that he has been cranky with a reduced level of activity. “He is always an active kid who prefers to play outdoors, but of late, he has been keeping indoors mostly.” The mother also states that JR has a low-grade fever and bad breath. He lacks appetite and has lost 5kgs in the past two weeks. She has been managing the cold with home remedies, including honey for the cough and warm lemon water with mint. She also gave him throat lozenges at some point. Despite all these, the symptoms have persisted. The patient denies feeling any pain but confirms pressure on the face.

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Past Medical History:  Year infection six months ago; was successfully treated.

Past Surgical History:  N/A

Medications:  no medication

Allergies: No allergies

Immunizations:  Up to date will all childhood immunizations.

Family History:  Mother has a history of recurrent depression. No history of diabetes, heart disease, arthritis, and other chronic conditions.

Psychiatric history: diagnosed with OCD at age 8 and was treated

Social History/Risk Factors: JR is the third child in his family. His older siblings are a 16-year sister and 14 years brother. They live in community housing. The father walked out and left them when JR was only 3 years old and did not give any support. The mother is a casual employee at a nearby hospital surviving on the minimum wage. JR attends school and records an average performance. Lately, however, the mother has noted he has become indifferent towards school, and he is asking questions about his father.

No tobacco smoking, alcohol use, or illicit drug use

Review of Systems:

General: (+) fevers, (-) chills, (+) unintentional weight loss/gain or changes in appetite, (-) changes in exercise ability, (-) fatigue.

Head: (-) headache, (-) dizziness, (+) sinus pressure (frontal and maxillary).

Eyes: (-) changes in vision, (-) blurred vision, (-) double vision, (-) floaters. Last eye exam: (-) redness, (-) drainage (-) watery eyes.

Ears: (-) changes or difficulty in hearing, (-) ear pain, (-) drainage.

Nose: (-) difficulty smelling, (+) runny nose, (+) congestion, (-) epistaxis

Mouth/Throat: (-) problems swallowing, (-) difficulty eating/chewing foods, (-) sores or lesions, (+) postnasal drip. Last dental exam: 23/8/2021

Neck: (-) stiffness, (-) pain, (-) left neck nodule, (-) reflux.

Respiratory: (-) difficulty breathing, (-) shortness of breath, (+) cough (-) dyspnea, (-) wheezing.

Cardiovascular: (-) chest pain, (-) abnormal heart beats, (-) skipped beats, (-) fluttering, (-) shortness of breath with exertion.

GI: (-) nausea/vomiting, (-) heartburn, (-) acid reflux, (-) pain with defecation, (-) rectal bleeding, (-) hemorrhoids. Bowel movement. (-) constipation, (-) diarrhea.

GU: (-) difficult urination, (-) painful urination, (-) urinary frequency.

GYN: (if applicable) (-) abnormal menstrual bleeding, (-) vaginal discharge/odor, last menstrual period (LMP).

Musculoskeletal: (-) painful bilateral legs, (-) pain joints, (-) problems with range of motion, (-) stiffness, (-) backaches.

Neurological: (-) weakness, (-) dizziness, (-) blurred vision, (-) unsteady gait, (-) changes in memory, (-) changes in mood.

Psychiatric: (-) depression, (-) anxiety, (-) sleep disturbances, (-) nervousness, (-) suicidal ideation, (-) suicidal attempts.

Skin: (+) changes in skin (swollen face) (-) rashes, (-) lesions.

Endocrine: (+) weight loss or weight gain, (-) excessive sweating, (-) hair thinning/loss, (-) hot or cold intolerance, (-) excessive thirst.

Hem/Lymph: (-) bruising or getting sick easily, (-) excessive healing time, (-) anemia.

Objective

Vital Signs:

BP 66/106 Pulse 98, Respiratory Rate, Height 2 6″, Weight 30 kg, T 37.5 ⁰C

General: Alert and oriented to time and place, appropriately dressed for the weather. Affect dull.

Neurological: no dizziness, seizure, or syncope

HEENT: No blurred vision, no red-eye, and no hearing loss. Nasal congestion, postnasal drip, running nose, sinus pressure, cough with yellow-green sputum, pressure, and sensation on the face. Sinus tenderness.

Neck: no neck pain

Lymph Nodes: swollen, inflamed lymph nodes

Respiratory: Non-productive cough, difficulties in breathing

Cardiovascular: no chest pain or pressure, S3 and S4 murmur

GI: no vomiting, diarrhea, nausea, or abdominal pain. All four quadrants non-tender to palpation.

Back: no back pain

Musculoskeletal: no pain or swelling to the extremities. Normal ROM

Skin: no rashes or inflammation, positive for face swelling

Psychiatric: Mood and affect blunt.

Assessment

Nasal endoscope – a doctor uses an instrument with a lens at the end to observe the inside part of the nose for swelling, congestion, and infection (Balqurun et al., 2020).

Working diagnosis

Acute Sinusitis (pediatric) ICD-10 code: J01. 90

In acute sinusitis, patient history and physical examination data are enough to make a clinical diagnosis. The patient and his mother report several symptoms, including cough with green sputum, postnasal drip, slight fever, nasal congestion, irritability, and sinus pressure, consistent with acute sinusitis’s clinical manifestations. The symptoms have been present for more than 14 days. Additionally, examination reveals swollen lymph nodes, sinus tenderness, swollen face, and sinus pressure, which support the diagnosis. Finally, the nasal endoscopy also reveals swelling, infection, and congestion, further confirming the diagnosis (Leung et al., 2020).

Differential diagnosis

1. Pneumonia – the green sputum and presence of fever potentially indicate the presence of pneumonia. However, the other symptoms rule out the possibility of pneumonia in this case (Dale et al., 2019).
2. Bronchitis – a cold lasting more than 7 days could also be a sign of bronchitis. Additionally, cough, fever, and sputum are also symptoms of bronchitis, which are pertinent positives in JR’s case. However, the absence of chest discomfort/pain/congestion, chills, vomiting, and back pain limits the possibility of bronchitis (Dale et al., 2019).
3. Ear infection – the patient has a history of year infection. Additionally, year infection symptoms are similar to symptoms of sinusitis. However, physical examination rules out an ear infection.

Problem list

1. Symptoms of cold
2. Poor socio-economic condition
3. Weight loss

Plan

Diagnostic tests

Sinus X-ray –       the exam gives a cross-sectional view of the sinus to support the diagnosis.

CT Scan – enables extensive observation of the anterior ethmoid cells to identify the origin of the sinusitis (Battisti et al., 2022).

Pharmacology

– Amoxicillin-clavulanate 45 mg tab PO divided into two doses for 5 days (Zhu et al., 2021)

– Oxymetazoline for nasal decongestion

Non-pharmacology treatment

• Give the child a lot of fluids
• Use a humidifier at night

Patient education

–              Importance of adherence to treatment regime. Instructed the mother not to stop medication without consulting the provider. Advised to give antibiotics after meals and observe any side effects (Balqurun et al., 2020).

– Stay hydrated and get good rest

– Washing hands thoroughly and covering mouth while coughing

– the importance of providing nutritional meals and healthy eating

Referral

• Referred to a social worker for support with resources such as better employment opportunities to improve health, welfare, and wellbeing.
• Referred to a nutritionist to advise on food that can boost appetite and weight gain.

Follow-up plan

–              Follow-up after one week to review progress with medication and symptoms remission. If the symptoms persist, a change of medication will be considered.

References

Balqurun, H. M., Hassan, A., & Allehaib, A. (2020). Sinusitis, Evaluation, and Management in Primary Health Care: Literature Review. Archives of Pharmacy Practice, 11(11).

Battisti, A. S., Modi, P., & Pangia, J. (2022). Sinusitis. Treasure Island (FL): StatPearls Publishing.

Dale, A. P., Marchello, C., & Ebell, M. H. (2019). Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis: a meta-analysis. The British journal of general practice. The Journal of the Royal College of General Practitioners, 69(684), e444–e453.

Leung, A. K., H. K., & Chu, W. C. (2020). Acute bacterial sinusitis in children: an updated review. Drugs in context, 9,9-3. https://doi.org/10.7573/dic.2020-9-3.

Zhu, J., Lin, W., Yuan, W., & Chen, L. (2021). New Insight on Pathophysiology, Diagnosis, and Treatment of Odontogenic Maxillary Sinusitis. Journal of Nanomaterials, https://doi.org/10.1155/2021/9997180.

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Summarize and discuss the clinical characteristics and identify the appropriate laboratory, imaging, and other diagnostic and screening tools that apply to this condition or disorder. Explain why you selected these tests or tools as being appropriate to this process. Support your summary and recommended plan with a minimum of two APRN-approved scholarly resources.