CC: 36 y.o. single white female with a hx of type I IDDM since the age of 16 presents to the office for her routine follow up of DM, and also reports a 2 week history of sinus pain, headache, and nasal congestion. Pt is a reliable historian. S: Pt reports a 2 week history of frontal headache; frontal sinus pain; ear congestion; clear rhinitis; nasal congestion; pharyngitis; waxing and waning fever with Tmax of 101. Last temp noted yesterday morning. She also admits to mild, occasional, dry cough which is worse at night. Sx are not getting worse, but are also not improving. Has taken various OTC meds with minimal effect. Tylenol 650 mg qd to bid prn for fever. Has no history of frequent or recurrent URI or sinusitis. No chronic respiratory illnesses. NO hx of environmental allergies. Non smoker/no smoke exposure. No ill known ill contacts. Appetite has been fair. Drinking fluids. Denies dizziness, SOB, wheezing, chest pain, NV. LMP-1 week ago, normal. Uses OCPs as d

Date

 

Acute Exacerbation of a Chronic Problem

 

SOAP Note

Patient Initials: A.L.               Age: 69 years old           Race: White       Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): “I am getting unexplained headache and I wake up between sleep at night. I also have recurrent suicidal thoughts.”

History of Present Illness (HPI): A.L. is a 69-year-old white female patient who has visited the clinic for a follow-up visit. She was in the clinic for her first visit 2 weeks ago. Her reason for visiting the clinic today is that she needs help with problematic symptoms that started 48 hours ago. As reported by A.L., she has been getting unexplained intermittent headache in the past 2 days and is unable to sleep comfortably for the last two nights due to insomia. She reports feelings of worthlessness currently and has recurrent suicidal thoughts.

During her last visit to the clinic, A.L. was diagnosed with depression due to symptoms which had lasted for 6 months. At that time, she had multiple symptoms including a depressed mood, loss of interest in activities, excessive sleep, lack of energy, and reduced appetite. A.L. also reported anxiety and agitation, feelings of worthlessness, and a mild headache. These symptoms began six months ago as per her initial report and were the reasons for her initial finish. A.L. further states today that she thinks that she will not recover from her current status because she has started to develop other problems since her last visit to the clinic.

Following her diagnosis two weeks ago, the doctor prescribed 2.5 mg of Valium (Diazepam) which she has been taking twice a day for two weeks now. The doctor also prescribed Zoloft (Sertraline) at a dose of 25 mg orally daily. As reported by A.L., her anxiety has reduced significantly since she started to use the drug. However, she reports strange symptoms since she started to use the named medications. These include occasional seizures, vision changes, weakness, and poor memory. She reports that she ignored the symptoms thinking that they will disappear with time and denies drug non-adherence. These strange symptoms that started about 10 days ago, together with those that began 2 days ago, have negatively affected her quality of life.

Medications:

• 5 mg of Valium (Diazepam) twice a day
• Zoloft (Sertraline) at a dose of 25 mg orally daily

Allergies: Denies drug and food allergies.

Past Medical History (PMH): A.L. denies being diagnosed with a serious medical condition before. However, she reports several occasions of fever which were effectively managed using painkillers. The patient cannot recall whether she was hospitalized due to any medical conditions during her childhood.

Past Surgical History (PSH): Denies surgical history.

Sexual/Reproductive History: A.L. reports that she is happily married with two children, a girl and a boy. Her children are currently teenagers and they are in college. A.L. further states that she used Brevicom, an oral contraceptive pill, for 15 years. She is still sexually active.

Personal/Social History: A.L. is a retired accountant. She used to work as the finance manager in a nearby coffee factory. Her husband is a retired teacher who currently owns a private school. The two normally stay at home most of the time because their ability to move around is hampered by their reduced physical mobility. As reported by A.L., she consumes neither alcohol nor cigarettes.

She also denies using illicit drugs such as heroin and cocaine. She is a Christian of the Catholic faith who also acts as a leader in her church. A.L. reports eating a balanced diet full of fruits and vegetables. Before her current symptoms, A.L. used to perform house chores and complete activities of daily living comfortably without difficulties. Completing them has been quite a challenge since she started to fall ill.

Immunization History: A.L.’s medical records indicate that she received all her immunizations according to schedule.

Significant Family History: A.L. has lost both parents. Her mother died three year ago at the age of 82 due to cardiac complications. Her father who was an engineer died 10 years ago at the age 89 years. She has one brother who is still alive and has never been diagnosed with a serious medica

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