Nurs 6512 Wk 5 Discussion All Answers 100% Correct Aid Grade A+

Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he's taken Mucinex OTC the past two nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. Episodic/Focused SOAP Note Patient Information: R.B., 50 year old Caucasian Male. Subjective. CC: “Nasal Congestion and Itching x 5 days” HPI: R.B. is a 50-year-old white male complaining of nasal congestion, sneezing, rhinorrhea, postnasal drainage, and itchy nose, eyes, palate, and ears for 5 days. The patient reports taking Mucinex OTC to help breathe at night, but relief has been minimal. Denies headache or pain. Medications: Mucinex OTC 1 tab orally every night. Allergies: NKDA, reports seasonal allergies. PMHx: No significant medical history. Denies illnesses or surgeries. Hospitalized in 2002 for back injury following a motor vehicle accident. Up to date on his immunizations, received his flu shot this season. Soc Hx: Married with 2 children ages 12 and 14. X-smoker, quit in 2006. Drinks alcohol occasionally reports once or twice per month. He has a Bachelor’s degree in business, and runs his own consulting firm. He enjoys surfing and snowboarding with his family. Uses seat belt, and denies using cell phone while driving. He exercises regularly, and eats a heart healthy diet. Sleeps well, but not for the past 5 nights since his symptoms started.