Prompt Title: Sinusitis SOAP Note

Sure, here's an example of an average SOAP note for sinusitis:

Subjective: The patient is a 33-year-old male who presents with complaints of facial pain and pressure for the past week. He reports experiencing nasal congestion and a productive cough with yellowish-green mucus. The patient denies having a fever, chills, or shortness of breath. He reports having a history of seasonal allergies and using over-the-counter antihistamines with some relief.

Objective: On physical exam, the patient is afebrile with normal vital signs. He has tenderness over the maxillary sinuses on palpation. His nasal turbinates are erythematous and edematous, and there is purulent discharge from both nares. There are no signs of tonsillar hypertrophy or pharyngeal erythema.

Assessment: The patient is diagnosed with acute sinusitis. The symptoms, physical exam findings, and history of allergies suggest a bacterial etiology. Differential diagnoses include allergic rhinitis, viral sinusitis, and nasal polyps.

Plan: The patient will be prescribed a 10-day course of amoxicillin/clavulanate. Symptomatic relief will be provided with nasal saline irrigation and an intranasal corticosteroid. The patient will be advised to follow up in 1 week to monitor for improvement and possible complications. If symptoms worsen or do not improve, a referral to an otolaryngologist may be necessary. Education on proper hand hygiene and infection control measures will also be provided.