HEENT SOAP.docx - SOAP Note Format Patient Information J.T 28y\/o African American female Unknown Insurance S CC Sore itchy throat and runny nose HPI

HEENT SOAP.docx - SOAP Note Format Patient Information J.T...

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SOAP Note FormatPatient Information:J.T., 28y/o, African American, female, Unknown InsuranceS.CC: Sore itchy throat and runny noseHPI: Onset: 1 week agoLocation: throat and noseDuration: constant runny nose, sore, itchy throatCharacteristics: constant runny nose with clear discharge. Describes throat pain as 4/10and sore.Aggravating Factors: denies aggravating factors for runny nose. Hurts more upon swallowing.Relieving Factors: sucking candies and drinking water improves throat symptoms. Denies relieving factors for runny nose. Treatment: Denies OTC medications Current Medications:Throat Lozenge (OTC) every 4 hours, for one week, as needed for sore throat Proventil MDI, 2 puffs every four hours, since 2.5 years old (initially diagnosed with Asthma), as needed for shortness of breathTylenol 500mg po 1-2 tabs, once a week, as needed for headaches secondary to squintingIbuprofen 200mg po 3 tabs, as needed for menstrual cramping, Allergies:Cats:cause runny nose, sneezing, and itching. Treats by avoiding cats, using inhaler if breathing problems occur, and goes home to shower Dust:causes sneezing, runny nose, and wheezing during prolonged exposure. Penicillin:(happened when she was young so unsure of exact reaction).
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  • Fall '15
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