NURS 6512 Week 4 Focused SOAP Note Example

Focused SOAP Note: Twelve Days of Unilateral Facial Pressure and Purulent Nasal Drainage in a 34-Year-Old Woman

Student Name

College of Nursing, Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Instructor Name

Month Day, Year

Subjective

The patient described here is an illustrative composite built for teaching, and no part of this note is drawn from a real encounter or a real record. E.G. is a 34-year-old woman who presents to a primary care clinic with, in her words, 'pressure in my right cheek that will not quit.' Symptoms began 12 days ago as clear rhinorrhea, sneezing, and a mild sore throat that she treated as a cold. She improved around day 5, then worsened on day 7 with right maxillary pressure, thick yellow-green drainage, and a temperature of 100.9 F measured at home. Pain is a dull, constant 6 of 10, worse when she bends forward and on waking, briefly better after a hot shower. Ibuprofen 400 mg every 6 hours brings it to a 4. She reports right upper tooth ache, reduced sense of smell, and postnasal drip with a nighttime cough. She denies visual change, double vision, neck stiffness, and facial swelling.

Her history includes seasonal allergic rhinitis diagnosed in her twenties and one episode of sinusitis four years ago treated with antibiotics. She reports no asthma, no immune deficiency, no nasal surgery, and no known polyps. Medications are cetirizine 10 mg daily, taken inconsistently outside spring, and a combined oral contraceptive; she uses no intranasal steroid. She reports an allergy to sulfamethoxazole-trimethoprim, which produced a diffuse rash at age 19, and no penicillin allergy. Family history includes atopy in her mother and hypertension in her father. She teaches middle school, lives with a partner and one school-age child who had a cold two weeks ago, has never smoked, drinks alcohol socially, and uses no recreational drugs. Immunizations are current, including influenza this season, and her last dental visit was 14 months ago.

A focused review of systems is positive for subjective fever, fatigue, and reduced appetite over the past five days; for right maxillary pressure, purulent nasal drainage, reduced smell, right ear fullness, and a mild dry cough that worsens when she lies down; and for right upper molar discomfort. It is negative for chills or rigors, weight loss, night sweats, periorbital swelling, eye pain with movement, blurred vision, light sensitivity, severe headache, neck stiffness, confusion, shortness of breath, wheeze, chest pain, rash, and joint pain. She has had no dental procedure, no head injury, no recent air travel, and no diving. She has missed three days of work and sleeps poorly because of congestion.

Objective

Vital signs are temperature 99.6 F oral, heart rate 82 and regular, respirations 16, blood pressure 118/74 seated in the right arm, oxygen saturation 99 percent on room air, weight 148 lb, height 65 in, body mass index 24.6, and pain 5 of 10. She is alert, well appearing, in no distress, and speaks with a mildly hyponasal voice. The external nose and face show no swelling, erythema, or crepitus. There is tenderness to palpation and percussion over the right maxillary sinus and none over the left maxillary or either frontal sinus. Anterior rhinoscopy shows boggy, erythematous turbinates bilaterally with mucopurulent drainage visible in the right middle meatus; the septum is midline, and the mucosa shows no ulceration, polyps, or foreign body. Transillumination is reduced on the right, recorded for completeness rather than for diagnostic weight (Ball et al., 2023).

The eyes show no periorbital edema, no proptosis, and no chemosis; extraocular movements are intact in all fields, pupils are equal and reactive, and visual acuity is 20/20 bilaterally by wall chart. Tympanic membranes are pearly gray with visible landmarks and normal mobility on pneumatic otoscopy, and there is no mastoid tenderness (Bickley et al., 2021). The oropharynx shows posterior mucopurulent drainage without tonsillar exudate, asymmetry, or uvular deviation. Dentition is intact, with no visible caries of the right upper molars and no tenderness on percussion of those teeth. Anterior cervical nodes are mildly enlarged and tender on the right at roughly 1 cm, mobile, with no supraclavicular nodes. Lungs are clear bilaterally without wheeze or crackles, and the heart has a regular rate and rhythm without murmur. Cranial nerves II through XII are intact, and there is no meningismus.

Testing was limited on purpose. A rapid antigen test for group A streptococcus was negative, ordered because of the sore throat and the tender node rather than because of the facial pain. No sinus radiographs, computed tomography, or laboratory studies were obtained. Imaging in uncomplicated acute rhinosinusitis does not separate viral from bacterial disease and is reserved for suspected complications or for treatment failure, so ordering it here would have added cost and radiation without changing the plan (Rosenfeld et al., 2015). The absence of periorbital findings, cranial nerve deficits, severe headache, and altered mental status is what makes that restraint defensible, and each was documented above for that reason.

Assessment and Plan

The working diagnosis is acute bacterial rhinosinusitis of the right maxillary sinus. Two of the three accepted presentations are present rather than one: symptoms persisting beyond 10 days without improvement, and worsening after an initial period of improvement, the pattern usually called double worsening (Rosenfeld et al., 2015). Unilateral maxillary pain with purulent drainage seen in the ipsilateral middle meatus points to a sinus source rather than a diffuse upper respiratory process, and the reduced smell and postnasal drip fit the same picture (Chow et al., 2012). Severity is moderate: she has been febrile at home, has missed work, and rates pain at 6 of 10, but she has no orbital, intracranial, or systemic toxicity findings. That distinction matters, because severity and duration together, not the color of the drainage, are what move the decision toward antibiotic therapy.

Four differentials were carried, and each was weighed against the same findings. Viral rhinosinusitis is the commonest cause of this presentation and would be the answer in most patients, but viral disease characteristically peaks by days 3 to 6 and improves by day 10, which this course did not do (Dains et al., 2020). Allergic rhinitis is plausible given her atopy and probably contributed to the mucosal edema that obstructed the sinus outflow tract, but allergic disease is bilateral, itch-predominant, and afebrile, and it does not produce unilateral purulence. Odontogenic sinusitis earned active exclusion because right upper molar pain accompanies it and because it changes treatment; intact dentition, absent caries, and nontender percussion argue against it, although dental evaluation stays in the plan. Migraine and trigeminal neuralgia were considered and set aside, since the pain is dull and positional rather than throbbing or lancinating, with no aura and no trigger zone.

The plan pairs treatment with a stated review point. Amoxicillin-clavulanate 875 mg/125 mg by mouth twice daily for 7 days is prescribed, chosen over amoxicillin alone for beta-lactamase coverage and over a macrolide or a trimethoprim-based agent because of resistance patterns and her documented sulfonamide reaction (Chow et al., 2012). Symptom care is saline nasal irrigation twice daily, fluticasone propionate 50 mcg two sprays in each nostril daily, and ibuprofen 400 mg every 6 hours as needed with food. She was taught that most sinus infections are viral and resolve without antibiotics, which is the stewardship message this visit should carry (Centers for Disease Control and Prevention, 2024). Return precautions were specific: periorbital swelling, vision change, severe headache, neck stiffness, confusion, or fever above 102 F warrants same-day evaluation. Follow-up is set for 7 days, sooner if she is not improving by day 3, with dental referral if pain localizes to the molars.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Centers for Disease Control and Prevention. (2024). Sinus infection (sinusitis). U.S. Department of Health and Human Services. https://www.cdc.gov/antibiotic-use/sinus-infection.html

Chow, A. W., Benninger, M. S., Brook, I., Brozek, J. L., Goldstein, E. J. C., Hicks, L. A., Pankey, G. A., Seleznick, M., Volturo, G., Wald, E. R., & File, T. M. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases, 54(8), e72-e112.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Ashok Kumar, K., Kramper, M., Orlandi, R. R., Palmer, J. N., Patel, Z. M., Peters, A., Walsh, S. A., & Corrigan, M. D. (2015). Clinical practice guideline (update): Adult sinusitis. Otolaryngology-Head and Neck Surgery, 152(2 Suppl), S1-S39.