NSG 6420 Week 2 SOAP Note Assignment | South University, Savannah

Document Content and Description Below

Week 2 SOAP Note Assignment SU_NSG6420_W2_A3_Alimole_A.doc. South University NSG 6420 December 13, 2020 2 Week 2 SOAP Note Assignment SOAP Note Name: [email protected] Date: December13, 202... 0 Time: 2:30 pm Age: 45 Sex: M SUBJECTIVE CC: Nasal congestion and pain on the left side of the face for the past three days. HPI: The patient reported experiencing pain on the left side of the nose and nose congestion for the past three days. He also c/o itchy throat and cough. He also reported that the pain gets worse when he bends forwards and worsening of cough on lying down or doing physical activity. He describes the pain as a throbbing. The patient reports that the pain is in the left side of his nose that radiates to his left jaw. He additional reported generalized sporadic dull headaches unrelated to any precipitating events. He rated the severity of pain on a scale as 4/10. The patient stated that the pain is mainly in the morning when he wakes up but constant throughout most the day. He reported having a low-grade fever and feeling fatigued and reported trouble sleeping due to nasal congestion and cough. He mentioned taking over the counter (OTC) Tylenol for fever and pain and experienced much relief. He also reported using cough drops but experienced minimum relief. He denied feeling nauseous, denied vomiting, shortness of breath, and rashes on the skin. Medications: The patient is currently not taking any prescribed medication. He reported taking OTC Tylenol for pain and fever and cough drops for cough. He denied taking any herbal medication or nutrition supplements. 3 PMH: The patient denied having any significant medical history other than seasonal flu. Allergies: The patient did not report any drug, food, or seasonal allergies. Medication Intolerances: The patient did not report intolerance to any medication. Chronic Illnesses/Major traumas: The patient denied suffering from any chronic illness or experiencing major trauma. Hospitalizations/Surgeries: The patient had no history of hospitalization or surgeries. Family History The paternal grandfather deceased and suffered from dementia. The paternal grandmother deceased and suffered joint pain and diabetes. The maternal grandfather deceased and was healthy overall. The maternal grandmother deceased and was obese and suffered from joint pain and hypertension. Father is alive and suffers from diabetes and hypertension. Mother is alive and obese and suffered from joint pain and hypertension. Has one elder sister who is obese and suffers from diabetes. Has o [Show More]

Last updated: 1 year ago

Preview 1 out of 11 pages