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Sinusitis Diagnosis and Assessment Plan (Case Study Sample)


VITALS: 120/78 P:75 RR:18 PO2:99% TEMP:98.6
For your note this week, create an HEENT related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use an HEENT related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints. Examples: sore throat, ear ache, hearing loss, eye drainage, etc.).
Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citations, and reference format. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).
The ROS and physical exam in your document should be written up as they would be for a problem focused (SINUSITIS)visit. The HEENT part of the physical exam write up should be a comprehensive write up,


Sinusitis Diagnosis and Assessment Plan
Sinusitis Diagnosis and Assessment Plan
Chief Complaint: 21-year-old Hispanic with sinusitis
History of Present Illness
* The patient says that he has been experiencing cold symptoms for ten days.
* Besides, she has had a running nose with a green discharge for a week.
* The patient has a persistent, productive cough, producing green sputum. She has been coughing for 14 days.
* Other symptoms include a sore throat and a raw throat.
* The cough becomes worse when she engages in an activity or lying down.
* Besides, she has been experiencing intermittent headaches.
* The cough causes sleeping difficulties.
* She has not experienced shortness of breath, rash, fever, vomiting, or oral intake reduction.
* Two weeks ago, her sister was diagnosed with pneumonia.
* She has no history of any allergy.
Review of Systems
The patient has a history of cerebral palsy. She has been showing regular improvements after undergoing occupational therapy. She has mild fatigue and no fever.
* Her throat has a raw feeling, especially after coughing.
* The patient has constant nasal congestion with a runny nose producing a greenish discharge.
* There is no discharge from the eyes or irritation.
* She has no pain or discharge from the ears.
* The patient experiences sensation of pressure on the face and some pain.
* She has a strong, productive cough producing green phlegm.
* The cough worsens after exertion or when lying, but it does not cause difficulty in breathing.
* Her appetite has not been affected, and she has adequate oral intake. She has not experienced diarrhea, nausea, or vomiting.
* The patient has not experienced visual changes despite the intermittent headache.
* Finally, there are no recent changes in neurological function despite a history of cerebral palsy.
* The only medicine she has taken to manage the symptoms Cetirizine HCl 10mg acquired over the counter.
Other Histories
She has a sister who was recently diagnosed with pneumonia. There is no history of asthma or other respiratory illnesses in the family. She has no known allergies. The patient lives with her mother and older sister. She has no sickness contacts.
Physical Exam:
* Blood pressure: BP 104/60
* Weight: 54.6 kgs
* Heart Rate 66
* Respiratory Rate 20
* Temperature 36.2 c
* General:
* No acute distress
* Active during exam
* N exudates or lesions were found in the throat.
* The patient's hearing is intact.
* The ear canals are clear.
* The patient has no discharge in her conjunctiva, which is clear.
* The tympanic membranes are pearly grey with some marks. Her head is atraumatic and normocephalic.
* The mucus membranes have no mucosal lesions, and they are moist.
* Upon palpitation, her frontal and maxillary sinuses are tender.
* Her breath sounds clear; the neck has no lymphadenopathy, the skin has no rashes, and is not excessively dry.
Differential Diagnosis
Diagnosis 1: Sinusitis
Sinusitis is likely because the symptoms have lasted for more than ten days. The presence of green nasal congestion, a persistent cough, and sinus tenderness also increase the likelihood of the condition being sinusitis (Ah-See, 2015). The intermittent headache is also a sign of the disease
Diagnosis 2: Viral Respiratory Infection
The nasal congestion, dry cough, sore and raw throat, and absence of fever indicate a possibility of a viral upper respiratory infection. However, the prolonged presence of symptoms, sinus tenderness, intermittent headache, and lack of symptom improvement decrease the probability of a viral upper respiratory infection.
Diagnosis 3: Pneumonia
A recent pneumonia diagnosis in the family and persistent cough with green sputum increase the probability of pneumonia. However, pneumonia is less likely due to the existence of a clear breath, absence of fever, and sinus tenderness.
Due to symptoms such as nasal discharge, which is green in color, and a cough lasting more than ten days without improvement, a diagnosis of sinusitis can be made. The diagnosis is supported by the physical exam results of sinus tenderness.
Diagnostic P

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