NURS 6512: Advanced Health Assessment and Diagnostic Reasoning Week 5 Discussion Case #1 Episodic/Focused SOAP Note Template

Patient Information: R.P., 50-year old Caucasian male S: CC: Itchy eyes, ears, nose, and palate x 5 days HPI: R.P. is a 50-year old Caucasian male that presents to the clinic with a complaint of rhinorrhea, sneezing, nasal congestion and postnasal drip with itchy eyes, ears, nose, and palate for the past 5 days. The patient reports facial pressure around his eyes and nose. There is a moderate amount of clear drainage from the nose with persistent congestion. He also reports a slight sore throat upon awakening in the morning for the past 2 to 3 days that typically resolves without intervention by mid-morning. The patient states the symptoms are worse in the early morning and late evening. The patient has tried Mucinex OTC x 2 days to help him breath at night with minimal relief. On a scale from 0 to 10, 0 being no pain and 10 being the worst pain imaginable, the patient rates h