Name: Julie S. Date : 09/10/2019 Time : 1030
DOB: 5/7/1984 Sex: F
Subjective
CC: “I’ve had a cold for over a week and cannot shake it. It just seems to get worse.”
HPI: Patient presents to clinic c/o dry non-productive cough when lying down, and itchy sore
throat for 7 days. Patient then also started having sinus tenderness and ear pressure along with
previously stated symptoms for the past 4 days. Patient states these symptoms are worse while
outside for extended periods of time. Pt has not been taking any OTC medications for this and
cannot think of anything that helps alleviate the symptoms. Patient reports she has seasonal
allergies but does not take any medication regularly for it.
Medications: None
m
er as
Allergies: Sulfa Drugs-mild- causes rash
co
eH w
PMI
o.
Illnesses/Injuries
rs e
Childhood- Asthma, seasonal allergies
ou urc
Adult- Asthma, Seasonal allergies
Hospitalizations/Surgeries: None
Vaccinations
o
Influenza- September 2018 Pneumovac- Never
aC s
Health Maintenance:
vi y re
Last comprehensive physical exam- March 2019
Last pap smear- April 2019
FH:
Stroke: Paternal grandfather, Father
ed d
Diabetes: Father
ar stu
Lung disease: None
HTN: Paternal grandfather, Father
Heart disease: Paternal grandfather, Father
is
Cancer: None
SH: Lives alone and works days delivering mail.
Th
Tobacco-Denies ETOH-Denies Illicit drugs-Denies
ROS
sh
General: Denies weight change, fatigue, Ears: Denies tinnitus, vertigo, discharge, or use
weakness, or night sweats. Patient does of hearing aids. Does report muffled/ decreased
report frequent chills the last four days but hearing, ear pressure/ pain and a popping
not own a thermometer and is unsure if she sensation with yawning, swallowing, and when
has had a fever. blowing her nose.
This study source was downloaded by 100000829907498 from CourseHero.com on 08-16-2021 19:02:38 GMT -05:00
https://www.coursehero.com/file/76767716/EENT-SOAP-note-Tiffany-Partindocx/
DOB: 5/7/1984 Sex: F
Subjective
CC: “I’ve had a cold for over a week and cannot shake it. It just seems to get worse.”
HPI: Patient presents to clinic c/o dry non-productive cough when lying down, and itchy sore
throat for 7 days. Patient then also started having sinus tenderness and ear pressure along with
previously stated symptoms for the past 4 days. Patient states these symptoms are worse while
outside for extended periods of time. Pt has not been taking any OTC medications for this and
cannot think of anything that helps alleviate the symptoms. Patient reports she has seasonal
allergies but does not take any medication regularly for it.
Medications: None
m
er as
Allergies: Sulfa Drugs-mild- causes rash
co
eH w
PMI
o.
Illnesses/Injuries
rs e
Childhood- Asthma, seasonal allergies
ou urc
Adult- Asthma, Seasonal allergies
Hospitalizations/Surgeries: None
Vaccinations
o
Influenza- September 2018 Pneumovac- Never
aC s
Health Maintenance:
vi y re
Last comprehensive physical exam- March 2019
Last pap smear- April 2019
FH:
Stroke: Paternal grandfather, Father
ed d
Diabetes: Father
ar stu
Lung disease: None
HTN: Paternal grandfather, Father
Heart disease: Paternal grandfather, Father
is
Cancer: None
SH: Lives alone and works days delivering mail.
Th
Tobacco-Denies ETOH-Denies Illicit drugs-Denies
ROS
sh
General: Denies weight change, fatigue, Ears: Denies tinnitus, vertigo, discharge, or use
weakness, or night sweats. Patient does of hearing aids. Does report muffled/ decreased
report frequent chills the last four days but hearing, ear pressure/ pain and a popping
not own a thermometer and is unsure if she sensation with yawning, swallowing, and when
has had a fever. blowing her nose.
This study source was downloaded by 100000829907498 from CourseHero.com on 08-16-2021 19:02:38 GMT -05:00
https://www.coursehero.com/file/76767716/EENT-SOAP-note-Tiffany-Partindocx/
