NURS 612 SOAP NOTE ASSIGNMENT 3.3 EENT DOCUMENTATION

____________________________ Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow-up plan) Lani Doloroso Chief Complaint What brought you here today…(e.g. headache) Sinus Infection, headache, and sinus pressure History of Present Illness Chronological order of events, state of health before the onset of CC, must include OLD CARTS in paragraph form An onset Middle age Caucasian female patient came to the clinic with chief complaints taken a sinus infection that started with a headache and sinus pressure started two weeks before the clinic visit. She reported having three sinus infections in the last six months and was on antibiotics three months ago for similar symptoms. She said that the pain is located above and below her eyes along with right-sided ear pain. It described the pain as “pressure” in her ear when she swallows and is “able to smell it a little bit” when she was referring to nasal congestion. She got a headache along with sinus pressure too. It was mentioned that she coughs and has a little bit of a sore throat sometimes at night and has no pain in her chest. The ear pain is different from her past sinus infections. Denies any breathing problems or wheezing. Denies joint pain. No reported fever, chills, or cervical lymph node pain. The patient has utilized OTC Tylenol for the headache and OTC Sudafed for the congestion with minimal relief. She mentioned that she has seasonal allergies but does not use any medication for this and has not seen an allergist. She visited an EENT doctor five years ago for nasal polyps for which she was getting steroid injections every six months but did not go back for a follow-up. Location Duration Character Aggravating/associated factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications Allergies: Aspirin, seasonal allergies Adult Illnesses: History of chronic sinus infections, three times in the last six months, and nasal polyps Childhood Illnesses: Not addressed Surgeries: Nasal polyps (five years ago) Current Medications: Tylenol for fever and Sudafed Family History Include Parents, siblings; grandparents if applicable/known, cause of death, age, and pertinent medical illnesses Family history: Not addressed