Assignment 3.3 ENT Examination 1-2.docx - Assignment 3.3...

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Assignment 3.3: EENT Documentation Nusrat Kaleem Chief Complaint: Nasal congestion and headache, “I think I have a sinus infection” History of Present Illness: A middle-aged Caucasian female presents to the office reporting as a sinus infection. Patient reports the following symptoms for the last two weeks: pressure, a terrible headache, congestion, cough upon lying down, little bit sore throat at night and upon waking up, a bit of pain in ears. Pt denies any wheezing, difficulty breathing, chest pain, fever, chills, sweat, fever, joint pain. Pt stated “I've had headache and kind of pain up here and down here, and I know it sounds gross, but I can actually kind of smell it a little bit”. Pt c/o right ear pain on swallowing, feels like pressure. Pt taking Tylenol for headache and Sudafed without any relief in symptoms. Past Medical History: Adult Illnesses: No information provided in the case study Childhood Illness: No information provided in the case study Allergies : Aspirin (no reaction or severity mentioned in the interview) Immunization: Information not provided Medical History: history of sinus infections 3 within 6-month period, seasonal allergies Surgeries: history of nasal polyps, removed five year ago Current medication: Tylenol & Sudafed (no dose or time available in the history) Past medication: antibiotics 3 months ago, steroids shots every 6 months which were abruptly stopped (not sure of last dosage) Family History : Family history not taken in examination Personal/Social History

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