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Exam (elaborations)

NURS 612 Assignment 1.1 Typhon Tracking System and Sample Case

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NURS 612 Assignment 1.1 Typhon Tracking System and Sample CaseSample Case Log Complete 5/10/2019 S.O.A.P. Note Template CASE ID# Sample Case Chief Complaint Cold symptoms History of Present Illness Mr. Samuel Grayson, a 55 y/o Caucasian male presents today with a "cold" that started about "5-7 days ago." He complains of nasal congestion with drainage, fatigue, and a cough that occurs in the morning that is productive. He states his sputum is green to yellow and thick in the morning when it is expelled. He has no complaints of pain at this time. He has not been taking any medication prescription or OTC for his symptoms at this time. He does not have a history of sinus infections or seasonal allergies. Past Medical History He has no significant past medical history. Childhood illnesses: He is up to date on his childhood immunizations. Current immunizations: He received the flu and pneumonia vaccinations in 2018. Allergies: He has allergies to sulfa medications which gives him rash and hives. Current medications: None Surgical history: None Family History Negative family history.

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