SOAP NOTE 1
SOAP Note Sinusitis
Mary Ann Smith
United States University
FNP592 Common Illness Across The Lifespan
Dr. Josenti
August 25th, 2025
, SOAP NOTE 2
SOAP Note
SUBJECTIVE:
ID: M.T. 40 years of age. High School teacher. Reliable historian. Drove by herself to our office
today.
CC: "I feel heavy on my head and clogged up in my nose."
HPI:
OLDCARTS:
● Onset: Seven days ago
● Location: Frontal and maxillary sinuses
● Duration: Persistent during past seven days
● Characteristics: Facial fullness, nasal congestion, slight headache, mucous nasal
discharge
● Aggravating Factors: Leaning forward increases discomfort.
● Relieving Factors: Nasal spray offers relief.
● Timing: Aggravates at early hours.
● Severity: Pain and discomfort is 6/10 on pain scale.
PMH: No surgeries, no hospitalizations. Denies tobacco, alcohol, illicit drugs. No allergies to
drugs, food or environment. Married ten years. One son is 8 years old. LMP 7/30/25.
SOAP Note Sinusitis
Mary Ann Smith
United States University
FNP592 Common Illness Across The Lifespan
Dr. Josenti
August 25th, 2025
, SOAP NOTE 2
SOAP Note
SUBJECTIVE:
ID: M.T. 40 years of age. High School teacher. Reliable historian. Drove by herself to our office
today.
CC: "I feel heavy on my head and clogged up in my nose."
HPI:
OLDCARTS:
● Onset: Seven days ago
● Location: Frontal and maxillary sinuses
● Duration: Persistent during past seven days
● Characteristics: Facial fullness, nasal congestion, slight headache, mucous nasal
discharge
● Aggravating Factors: Leaning forward increases discomfort.
● Relieving Factors: Nasal spray offers relief.
● Timing: Aggravates at early hours.
● Severity: Pain and discomfort is 6/10 on pain scale.
PMH: No surgeries, no hospitalizations. Denies tobacco, alcohol, illicit drugs. No allergies to
drugs, food or environment. Married ten years. One son is 8 years old. LMP 7/30/25.
