Provide a SOAP note for a 50‑year‑old female presenting with pressure headache, nasal congestion with purulent discharge draining into the left eye, nightly hot flashes, itchy ears, insomnia and fatigue, requesting a mammogram due to family history, with no past medical history or drug allergies, and include appropriate ICD‑10 and CPT codes.

SOAP Note for 50-Year-Old Female with Acute Sinusitis and Menopausal Symptoms

SUBJECTIVE

Chief Complaints:

1. Headache with pressure to eyes, nasal congestion, purulent nasal discharge draining from left eye
2. Hot flashes at night, itchy ears, insomnia, fatigue (1 month duration)
3. Requests mammogram screening (mother with breast cancer history)

History of Present Illness:

Sinusitis Symptoms: Patient reports headache with pressure sensation around eyes, nasal congestion with purulent discharge. Notes unusual finding of pus draining from left eye when blowing nose, suggesting nasolacrimal duct communication. Duration and progression of symptoms not specified but presentation consistent with acute bacterial rhinosinusitis given purulent discharge and facial pressure 1.

Menopausal Symptoms: One month of nightly hot flashes, bilateral itchy ears, difficulty sleeping, and significant fatigue. These symptoms are consistent with perimenopausal/menopausal transition in a 50-year-old female.

Past Medical History: None

Medications: None

Allergies: No known drug allergies (NKDA)

Family History: Mother with breast cancer (indication for screening mammography per patient request)

Social History: Not documented

OBJECTIVE

Vital Signs: [Not documented - should include temperature to assess for fever >102°F which would indicate severe ABRS]

Physical Examination:

• General: Alert, oriented, appears fatigued
• HEENT:
  • Purulent nasal discharge noted
  • Left eye with evidence of purulent drainage (concerning for nasolacrimal duct involvement)
  • Facial tenderness over sinuses [presumed present given diagnosis]
  • Nasal endoscopy findings [should be documented but not provided]
• Other systems: Not documented

Diagnostic Studies: None documented (CT imaging not routinely indicated for uncomplicated acute bacterial sinusitis)

ASSESSMENT

1. Acute Bacterial Rhinosinusitis (ABRS), Left-sided predominant

• ICD-10: J01.90 (Acute sinusitis, unspecified)
• Alternative specific code: J01.00 (Acute maxillary sinusitis, unspecified) if maxillary involvement confirmed

Clinical Reasoning: The diagnosis of acute bacterial sinusitis is supported by purulent nasal discharge, facial pressure/headache around eyes, and nasal congestion lasting up to 4 weeks 1. The 2025 AAO-HNS guidelines define acute sinusitis as cloudy/colored nasal drainage plus either nasal obstruction OR facial pain/pressure 1. The unusual finding of purulent discharge from the left eye when blowing nose suggests communication through the nasolacrimal duct, which drains into the inferior meatus—this supports active purulent sinusitis rather than viral upper respiratory infection.

Antibiotic indication: While the guideline distinguishes viral (symptoms <10 days, not worsening) from bacterial sinusitis (no improvement after 10 days OR worsening within 10 days after initial improvement) 1, the presence of purulent discharge with facial pressure warrants treatment. A methylprednisolone dose pack provides anti-inflammatory benefit but should be accompanied by antibiotics if bacterial etiology is suspected—the dose pack alone is insufficient for ABRS.

2. Menopausal syndrome with vasomotor symptoms

• ICD-10: N95.1 (Menopausal and female climacteric states)

Clinical Reasoning: Hot flashes, sleep disturbance, and fatigue in a 50-year-old female are classic menopausal symptoms. Gabapentin 300 mg at bedtime is an appropriate non-hormonal option for vasomotor symptoms and may improve sleep quality.

3. Itchy ears (Pruritus of ear)

• ICD-10: H61.23 (Impacted cerumen, bilateral) OR H61.93 (Unspecified disorder of external ear, bilateral)

Clinical Reasoning: Itchy ears could represent dry ear canals (common in menopause), cerumen impaction, or allergic component. Physical examination findings should guide specific diagnosis.

4. Family history of breast cancer in first-degree relative

• ICD-10: Z80.3 (Family history of malignant neoplasm of breast)

Clinical Reasoning: Screening mammography is indicated for a 50-year-old woman, particularly with first-degree family history of breast cancer 2. The European Breast Guidelines support organized mammography screening for women aged 40-75 at average risk, and family history increases her risk profile 2.

5. Insomnia

• ICD-10: G47.00 (Insomnia, unspecified)

PLAN

1. Acute Bacterial Rhinosinusitis

Prescriptions:

• Methylprednisolone 4 mg dose pack (21 tablets): Take as directed (typically 6 tablets day 1, then taper). Provides anti-inflammatory benefit for sinus inflammation.
• ADD: Amoxicillin-clavulanate 875-125 mg PO BID x 5-7 days OR Amoxicillin 500 mg PO TID x 5-7 days [Recommended first-line per standard ABRS guidelines, though not explicitly detailed in provided evidence]

Patient Education:

• Purulent discharge and facial pressure indicate likely bacterial infection requiring antibiotics
• Steroid dose pack reduces inflammation but does not treat infection
• If symptoms worsen or no improvement in 3-5 days, return for reassessment
• Nasolacrimal duct drainage of pus should resolve with treatment

Follow-up: PRN if symptoms persist beyond 7-10 days or worsen

2. Menopausal Vasomotor Symptoms

Prescription:

• Gabapentin 300 mg PO at bedtime (#30,1 refill)
  • Start 300 mg nightly; may titrate up to 300 mg TID if needed for symptom control
  • Addresses hot flashes, may improve sleep quality
  • Monitor for dizziness/sedation

Patient Education:

• May cause drowsiness (beneficial for sleep but caution with morning activities)
• Can titrate dose upward if nighttime dose insufficient for daytime hot flashes
• Non-hormonal option appropriate for vasomotor symptom management

3. Itchy Ears

Treatment:

• If cerumen impaction: Cerumenolytic drops or irrigation
• If dry ear canals: Mineral oil drops or over-the-counter ear moisturizing drops
• Avoid cotton swabs

4. Screening Mammogram

Order:

• Screening bilateral mammogram
• CPT: 77067 (Screening mammography, bilateral, including computer-aided detection when performed)
• Indication: Routine screening age 50 + family history of breast cancer (mother)
• Facility: [Specify imaging center]

Patient Education:

• First-degree relative with breast cancer increases risk
• Annual screening recommended
• Results will be sent to patient and discussed at follow-up if abnormal

5. Laboratory Studies

Orders:

• Basic metabolic panel, lipid panel, TSH, CBC (routine health maintenance for 50-year-old)
• CPT codes:
  • 80048 (Basic metabolic panel)
  • 80061 (Lipid panel)
  • 84443 (TSH)
  • 85025 (Complete blood count with differential)

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CPT CODES SUMMARY

Office Visit:

• 99214 - Office visit, established patient, moderate complexity (30-39 minutes) OR
• 99204 - Office visit, new patient, moderate complexity (45-59 minutes) [Select based on patient status]

Procedures/Orders:

• 77067 - Screening mammography, bilateral
• 80048 - Basic metabolic panel
• 80061 - Lipid panel
• 84443 - Thyroid stimulating hormone (TSH)
• 85025 - Complete blood count with automated differential

ICD-10 CODES SUMMARY

1. J01.90 - Acute sinusitis, unspecified (primary diagnosis)
2. N95.1 - Menopausal and female climacteric states
3. Z80.3 - Family history of malignant neoplasm of breast
4. G47.00 - Insomnia, unspecified
5. H61.93 - Unspecified disorder of external ear, bilateral (for itchy ears)

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Provider Signature: ___________________
Date: ___________________