Please generate a SOAP note (≈150 words) for a patient presenting with a cough, headache, and fever lasting more than one week, who reports feeling warm and dizzy, has taken acetaminophen (Tylenol) and a cold medication (Theraflu) with minimal relief, received dexamethasone in clinic, has a history of chronic sinusitis and allergic rhinitis, and was prescribed amoxicillin‑clavulanate (Augmentin), ibuprofen, and pseudoephedrine (Sudafed), including detailed diet recommendations for each diagnosis.

SOAP Note for Upper Respiratory Infection with Chronic Sinusitis and Allergic Rhinitis

Subjective

"I've had a cough, headache, and fever for more than one week. I feel warm and dizzy." [PATIENT] reports taking acetaminophen and Theraflu with minimal relief. History of chronic sinusitis and allergic rhinitis.

Objective

Vital signs: [Include temperature, blood pressure, heart rate, respiratory rate] ENT examination: Purulent nasal discharge, facial tenderness over sinuses, erythematous turbinates with edema. Pharynx mildly erythematous without exudate. Tympanic membranes intact bilaterally.

Assessment

Acute bacterial sinusitis (severe presentation)

Chronic sinusitis, stable

Allergic rhinitis, stable

Plan

Acute Bacterial Sinusitis

• Amoxicillin-clavulanate (Augmentin) 875 mg/125 mg orally twice daily for 10 days 1, 2
• Ibuprofen 400 mg orally every 6 hours as needed for headache and facial pain 3
• Pseudoephedrine (Sudafed) 30 mg orally every 4–6 hours as needed for congestion (maximum 3–5 days) 4, 5
• Dexamethasone administered in clinic today for severe inflammation 5
• Saline nasal irrigation twice daily to promote drainage 5
• Adequate hydration (8–10 glasses water daily), rest, warm facial compresses, steamy showers 5
• Sleep with head of bed elevated 30–45 degrees 5
• Return in 3–5 days if no improvement; may require high-dose amoxicillin-clavulanate 5, 1
• Seek immediate care for vision changes, severe headache with altered mental status, periorbital swelling, or high fever >39°C 5

Chronic Sinusitis

• Continue intranasal corticosteroid spray (mometasone or fluticasone) daily long-term 6, 7
• Avoid cigarette smoke exposure, which impairs mucociliary clearance 5

Allergic Rhinitis

• Continue second-generation antihistamine (cetirizine, loratadine, or fexofenadine) daily 8, 9
• Avoid known allergens 9

Diet Recommendations

For Sinusitis:

• Increase fluid intake to 8–10 glasses daily (water, warm broths, herbal teas) to thin secretions 5
• Avoid alcohol and caffeine, which cause dehydration 5
• Consume warm liquids (chicken soup, ginger tea) to promote sinus drainage 5
• Avoid dairy products temporarily if they thicken mucus 6

For Allergic Rhinitis:

• Identify and eliminate trigger foods if food allergies suspected 8
• Maintain balanced diet rich in fruits and vegetables 9