Assignment 3.3 EENT Documentation.docx - S.O.A.P Note...

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S.O.A.P. Note Template CASE ID# Assignment 3.3 S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan) Chief mplaint What brought you here today…(eg. headache) Nasal congestion, “I think I have a sinus Infection” History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Patient is a pleasant Caucasian woman and an accurate historian. She reports “I think I have a sinus infection.” She reports having three sinus infections in the last six months and was on antibiotics three months ago for similar symptoms. She reports pain above and below her eyes along with right-sided ear pain that feels like “pressure” in her ear when she swallows. The ear pain is different from her past sinus infections. She also reports that she is “able to smell it a little bit” when referring to her nasal congestion. She also has had a headache along with the sinus pressure. She coughs and has a little bit a sore throat sometimes at night and has no pain in her chest but in her head with the coughing. She denies any breathing problems or wheezing. She denies joint pain. She does not think she has had a fever and denies any chills or night sweats.

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