Soap note Acute Frontal Sinusitis

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Semester:

Spring

Course:

MSN6150C Advanced Practice Pediatrics

Preceptor: 

REYES-CHOUZA, CARLOS 

Clinical Site:

IDEAL MEDICAL CENTER

Setting Type:

Patient Demographics

Age:

12 years

Race:

Black or African American

Gender:

Male

Insurance:

Medicaid

Referral:

No referral

Clinical Information

Time with Patient:

25 minutes

Consult with Preceptor:

15 minutes

Type of Decision-Making:

Moderate complexity

Reason for Visit:

New Consult

Chief Complaint:

Felling pressure behaving my eyes

Type of HP:

Detailed

Social Problems Addressed:

Sanitation/Hygiene Emotional Prevention  

Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment - Physical Assessment (Perf) General Skills - Vital Signs (Perf)

ICD-10 Diagnosis Codes

#1 - 

J01.10 - ACUTE FRONTAL SINUSITIS, UNSPECIFIED

CPT Billing Codes

#1 - 

99214 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 30-39 MIN

Birth & Delivery

Medications

# OTC Drugs taken regularly:

0

# Prescriptions currently prescribed:

0

# New/Refilled Prescriptions This Visit:

2

Types of New/Refilled Prescriptions This Visit: Analgesic/Antipyretic - NSAIDS Infectious Diseases - Penicillins  

Adherence Issues with Medications: Knowledge deficit  

Other Questions About This Case

Patient's Primary Language:

English

Smoking Assessment:

Never

Advanced Directive:

No

Packs per day: