Pharmacotherapy I 2017

Final SOAP Note

Name: Katie Rhiner DOB: 7/15/1988 Age: 29 Date: 7/31/2017

Wt: 120lbs Ht: 64 inches Temp:101 HR: 80 BP: 110/70 mmHg
O2 Sat: 98% RA BMI: 20.6 LMP: 7 months ago Normal Abnormal
Type of visit: New Pt. Physical Est. Pt Simple follow up
Interpreter: none

Chief Complaint: "I feel awful, congested, and my head hurts x 11 days

HPI: Katie Rhiner is a 29-year-old pregnant female who presents to clinic stating that she feels
awful, congested, and her head hurts. She states she has been running a fever has thick, yellowish
nasal discharge from her left nare, facial pain, nasal congestion, headache and fatigue. She states that
her symptoms began 10 days ago and she thought she was getting better after a few days, but she
took a turn for the worse again a couple days ago. She states she has intense left-sided facial pressure
when she bends forward to tie her shoes or pick up something. She has noticed a decreased ability to
smell and taste. She admits to occasional episodes of dizziness, tremors, and palpitations for the last
week. She has been taking acetaminophen as needed for fever, loratadine 5mg/pseudoephedrine
120mg every 12 hours as needed for congestion, but has had very little relief from her symptoms.
She states she was treated for a sinus infection about 4 weeks ago with an antibiotic that she only had
to take once a day for 5 days. She doesnt remember the name of the drug, but thinks it began with a
Z. She states that infection seemed to have cleared up after taking the antibiotic, and was
completely symptom free for a few days before her current symptoms began 10 days ago. She states
she rarely gets sick and has not had an infection like this for years prior to these episodes.

She is 24-weeks gestation with no other significant PMH. She is married and this is her first
pregnancy. She denies tobacco, alcohol, or illicit drug use. She currently takes a Prenatal vitamin
daily. She has NKDA. She is up to date on all her immunizations.

ROS: Check if Positive:

Gen: wt. loss wt. gain fever/chills fatigue/malaise denies all denies all others
Skin: rashes pruritus hair changes nail changes easy bruising dryness denies all
denies all others
Eye: vision changes (blurriness/diplopia) eye pain redness discharge itching photophobia
denies all denies all others
ENT: ear pain ear discharge hearing loss tinnitus loss of smell nasal discharge
nasal/sinus congestion sneezing pain or lesions in mouth sore throat
changes in voice or hoarseness denies all denies all others
CV: chest pain or tightness palpitations presyncope or syncope dyspnea at rest
dyspnea on exertion orthopnea paroxysmal nocturnal dyspnea peripheral edema
 claudication denies all denies all others
PULM: dyspnea cough sputum production wheezing hemoptysis denies all
denies all others
GI: abdominal pain abdominal distention nausea vomiting diarrhea constipation
heartburn dysphagia odynophagia change in color/caliber of stool melena
bright red blood in stool jaundice denies all denies all others
GU: increased urinary frequency urinary urgency dysuria hematuria change in urine color
change in urine odor nocturia incontinence denies all denies all others
Female: vaginal discharge itching dryness genital lesions dyspareunia menstrual problems
menopausal symptoms breast pain breast mass nipple discharge denies all
denies all others
Male: urethral discharge penile lesions scrotal/testicular pain/swelling trouble starting urination
trouble stopping urination erectile dysfunction denies all denies all others
MSK: joint pain stiffness redness swelling neck pain back pain denies all
denies all others
Neuro: head trauma loss of consciousness headaches seizures focal numbness focal tingling
focal weakness difficulty w/speech difficulty w/understanding vertigo gain problems
coordination problems tremors concentration/memory problems denies all
denies all others
Psych: feeling down/depressed anxious irritable suicide ideation denies all denies all others

Physical Exam:
Gen: Tired appearing female in mild distress
Skin: warm to touch, good turgor
HEENT: Normocephalic/atraumatic; PERRL; EOMI; thick, purulent, yellow-green nasal discharge;
mucosal hypertrophy (L>R) without evidence of nasal polyps; facial pain over left maxillary
and frontal sinuses. No oral lesions. No periorbital swelling. TMs intact bilaterally without
erythema or bulging. Pharynx mildly erythematous without tonsillar enlargement or
exudate.
Neck: supple, shoddy bilateral cervical lymphadenopathy
Lungs: CTAB
CV: RRR; no m/r/g
Abd: Gravid uterus; nontender, Normal Active BS x 4

Diagnostics (Labs/Imaging/Other): EKG - normal; rapid strep - negative

Assessment:
Acute Bacterial Rhinosinusitis

Plan:
Your rapid strep test came back negative and your EKG was normal. Based on your history
and physical exam findings of a fever, facial pain over your sinuses, yellow-green nasal
 discharge, headache and fatigue lasting over 10 days, I am diagnosing you with acute
bacterial rhinosinusitis. Rhinosinusitis is a common disorder related to the inflammation of
your nasal passages and sinus cavity, which is causing your symptoms of facial pain,
congestion, headache and fatigue.
Amoxicillin is the drug of choice in treating rhinosinusitis. However, due to your recent
antibiotic use of azithromycin, I would like to have you start taking two 1000mg extended
release tablets of Augmentin every 12 hours for 10 days. This medication is a combination of
Amoxicillin and Clavulanate that works by stopping the growth of bacteria. I am having you
take this second-line medication over other options because you have previously been given
a first line agent, azithromycin, 4 weeks ago. Additionally, this medication is safe to take in
pregnancy, and covers the likely bacterial species that could be causing your rhinosinusitis
(S. pneumonia, H. influenzae, and M. catarrhalis). The addition of Clavulanate provides better
coverage for H. influenzae and M. catarrhalis, because it is a beta-lactamase inhibitor, which
helps overcome bacterial resistance. Please take the entire course of antibiotics as directed.
o Your congestion, headache and facial pain should begin to improve within 2-6 days
after starting the medication. Your fatigue may last a while longer while your body
recuperates.
o You may experience diarrhea, nausea or vomiting with this medication. Take this
medication with food to avoid those adverse effects on your stomach. Additionally,
you may experience candidiasis also known as a yeast infection or vaginitis. To
avoid a yeast infection, wear loose, cotton underwear and get rest. If you experience
vaginal itching, cottage-cheese like discharge, or patches in your mouth contact the
office. You may also use a topical cream called Monistat, which can be purchased
over the counter, as this is safe in pregnancy.
o This medication may rarely cause a severe intestinal condition known as C. difficile-
associated diarrhea. This may occur during treatment or weeks after treatment has
stopped. Contact the office immediately if you develop persistent diarrhea,
abdominal or stomach pain, or blood/mucus in your stool.
o Do not take this medication if you have a history of liver disease or kidney disease.
Antihistamines like the Loratadine that you are currently taking have not been proven useful
to treat your symptoms of congestion. They may actually thicken the mucus in your nose,
and may make your symptoms worse. I would like you to stop taking that. Instead, to
alleviate your congestion, I can recommend using a humidifier, warm compresses, and
maintaining adequate hydration. You may also try using a neti-pot. Additionally, if you are
not getting adequate relief with these medications, I can prescribe oxymetazoline, also
known as Afrin. This is a topical decongestant that can be used to decrease the inflammation
in your nose. However, this should not be used for more then 3 days to prevent rebound
 congestion, and is a second-line medication in pregnancy. I would like you to first begin the
antibiotic treatment, hydrate adequately and rest. If after a few days you are not getting any
symptomatic relief, please call the office and I will prescribe this for you.
Education:
Take two 1000mg tablets of extended release Augmentin every 12 hours. You can take one
dose upon waking with breakfast to avoid GI effects, and another 12 hours later. Take this
medication twice a day for 10 days. Do not skip a dose, and complete the treatment regimen
until you finish the bottle.
o If you miss a dose, take it as soon as your remember. If it is near the time of the next
dose, skip the missed dose and resume your usual dosing schedule. Do not double
the dose to catch up.
Make sure to rest adequately and properly hydrate. This will help you recover as quickly as
possible.
I would like to see you back in the office in 10 days, at the end of your treatment to assess
how you are doing. By the end of your treatment you should be feeling much better.

Other:
Seek immediate medical attention if you experience a rash. This drug can commonly cause a
mild rash that is usually not serious, however you may not be able to tell it apart from a rare
rash that could be a sign of a severe allergic reaction.
Seek immediate medical attention if you notice any symptoms of a serious allergic reaction
including: rash, itching/swelling especially of the face/tongue/throat, severe dizziness, or
trouble breathing.

Signature: Estelle Legros

Barriers to treatment: Comprehends meds Response to meds Education Self-care plan
Logs Lifestyle Mood
 Mercer Bear Family Practice, LLC
3001 Mercer University Dr.
Atlanta, GA 30341

John Doe, MD Phone: 555-555-5555

Mercer PA Student, PA-S

Name: Katie Rhiner Date: 7/31/17

Address: 33 MyAddress Dr. DOB: 7/15/88

Atlanta, GA
30329

Augmentin 1000mg

#40

Sig: 2 1000mg tablets PO q12hr Augmentin x 20 doses for Acute

Bacterial Sinusitis

Refills: 0
May Substitute: Signature: Estelle Legros
Mercer PA Student, PA-S

Acute Sinusitis Treatment & Management. Medscape.

http://emedicine.medscape.com/article/232670-overview. Accessed July 31, 2017.

Sikes, Martha. Otitis/Sinusitis. [PowerPoint]. Atlanta, Ga: Mercer University

Physician Assistant Program; 2017. Accessed July 31, 2017.