SOAP Note

Subjective:

The patient presents with a 3-month history of sinus congestion without any accompanying fever or chills.

Objective:

Further evaluation is needed to determine the objective findings, which may include nasal endoscopy, imaging studies (e.g., CT scan of the sinuses), and allergy testing.

Assessment:

The differential diagnosis for the patient's condition can be categorized as follows:

• Single Most Likely Diagnosis
  • Chronic Rhinosinusitis: This is the most likely diagnosis given the prolonged duration of sinus congestion without fever or chills, suggesting a chronic inflammatory process rather than an acute infection.
• Other Likely Diagnoses
  • Allergic Rhinitis: This condition could cause chronic sinus congestion, especially if the patient is exposed to allergens over an extended period.
  • Nasal Polyps: These can obstruct the sinuses and lead to chronic congestion.
  • Deviated Septum: A structural issue that can impair sinus drainage, leading to congestion.
• Do Not Miss Diagnoses
  • Sinus Cancer: Although rare, it's crucial to consider in the differential diagnosis, especially if there are additional symptoms like facial pain, nasal obstruction, or bleeding.
  • Invasive Fungal Sinusitis: This is a serious condition that can present with chronic sinus symptoms and is particularly dangerous in immunocompromised patients.
  • Granulomatosis with Polyangiitis (formerly known as Wegener's Granulomatosis): A systemic vasculitis that can affect the sinuses and respiratory tract.
• Rare Diagnoses
  • Sarcoidosis: A systemic disease that can affect the sinuses among other organs, leading to chronic inflammation.
  • Eosinophilic Granuloma with Polyangiitis (Churg-Strauss Syndrome): Another form of vasculitis that can involve the sinuses.

Plan:

The plan would involve further diagnostic testing based on the suspected diagnoses, such as imaging, allergy testing, and possibly a referral to an ENT specialist for nasal endoscopy or biopsy if necessary. Treatment would depend on the final diagnosis but could include antibiotics for bacterial infections, corticosteroids for inflammation, or surgery for structural issues.