NURS 6512: Advanced Health Assessment and Diagnostic Reasoning Week 5 Discussion Case #1 Questions and Answers | Latest 2023/2024 (Graded A+)

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 his pain 3/10 which he describes the facial pressure from the congestion. Current Medications: Lisinopril 20mg once daily x 5 years for hypertension Atorvastatin 10mg every evening x 5 years for hyperlipidemia Mucinex OTC 400mg every 4 hours x 2 nights as needed for congestion Allergies: No known drug allergies; patient reports a history of season allergies to tree pollen (causes watery, itchy eyes, sneezing, and rhinorrhea) PMHx: History of hypertension, hyperlipidemia, seasonal allergies. Patient had a right inguinal hernia repair age 40 in 2009; denies ever being hospitalized. Last tetanus vaccine in 2014; flu vaccine in October 2018.