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S.O.A.P Note William Frederick CC: Worsening HA, Facial Pain, Fever
NURSING 622.
NURSING 622.
HPI: William, a 42 yo male presents with 14 day history of headaches following an URI. He notes headaches are worsening in intensity, 7-10 day history of facial pain, intermittent right tooth pain, sinus pressure, post-nasal drip that is cloudy and worsens at night, and recent onset of today right ear pain, which he notes is stabbing. Pt also admits to low grade fevers that began today, 100 F at home. He has taken Tylenol and sinus OTC medications with no relief. He finds changing position...
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