Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CRS, evaluation of symptoms, medication management, or consideration of surgical intervention.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of nasal and sinus symptoms:
Duration and frequency of symptoms (symptoms lasting longer than 12 weeks define CRS)
Facial pain or pressure (location, character, severity)
Nasal congestion or blockage
Rhinorrhea (runny nose) – character (clear, colored, purulent)
Postnasal drip
Loss of smell or taste
Facial fullness or pressure
Impact of symptoms on sleep, daily activities, and quality of life
Past Medical History:
Briefly summarize relevant past medical history, including:
Allergies (allergic rhinitis can contribute to CRS)
History of nasal polyps
Previous sinus surgeries
Presence of co-morbidities (e.g., asthma, cystic fibrosis)
Social History:
Inquire about exposure to environmental allergens (dust mites, pollen, mold).
Ask about smoking history (smoking can worsen CRS symptoms).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Head and Neck Exam:
Assess for:
Facial tenderness or swelling
Nasal discharge (character, purulence)
Presence of nasal polyps (soft, painless growths)
Signs of sinusitis on transillumination (technique using light to assess sinus blockage)
Endoscopy (if performed):
Briefly describe findings from nasal endoscopy, which allows visualization of the inside of the nose and sinuses.
Assessment (A):
CRS Type:
Classify the type of CRS based on symptoms and presence of nasal polyps (with or without polyps).
Severity of Symptoms:
Assess the severity of symptoms and their impact on the patient’s life.
Presence of Complications:
Evaluate for potential complications of CRS (e.g., sinusitis with facial cellulitis, orbital cellulitis).
Plan (P):
Medications:
Develop a medication regimen based on the type and severity of CRS. Options may include:
Intranasal corticosteroids (first-line therapy) to reduce inflammation.
Nasal saline irrigation to clear mucus and allergens.
Antihistamines (for allergic rhinitis)
Antibiotics (for acute bacterial sinusitis)
Allergy Management (if indicated):
Consider allergy testing and immunotherapy (allergy shots) to address allergic triggers.
Surgical Intervention (if indicated):
Discuss the possibility of surgery to remove polyps, open blocked sinuses, or improve drainage if medication fails to provide adequate relief.
Referral (if indicated):
Consider referral to an otolaryngologist (ENT specialist) for patients with complex CRS, recurrent infections, or requiring surgical intervention.
Follow-up:
Schedule follow-up visits to monitor symptom control, response to treatment, and assess for complications.
Define the frequency of follow-up based on disease severity, response to treatment, and presence of complications.
Patient Education:
Educate the patient about CRS, its causes, risk factors, and the importance of treatment adherence.
Provide information on proper use of nasal medications and nasal saline irrigation.
Discuss allergy management strategies if applicable.
Explain the benefits and risks of potential surgical interventions (if discussed).
Offer resources for support groups or educational materials on managing CRS.