100%(8)8 out of 8 people found this document helpful
This preview shows page 1 - 4 out of 11 pages.
Episodic/Focus SOAP NoteComprehensive SOAP TemplateIntroduction This comprehensive Note is intended to give a clear understanding of the patient health conditionand to aid in the development of a treatment. With this process it is easier to visualize and organize the information obtained from the provided scenario. By reviewing subjective data, objective data, Assessment, and developing a Plan order we aim to re-stablish appropriate health status to the patient. With this process it remarkably easier organizing ideas and create a picture of what the patient problems are, what need to be addressed now, and what requires long term planning or referrals. CASE STUDY #1: Students with the last names that start with (A-M)Focused Nose Exam Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he's taken the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinate’s, which obstruct airway flow, but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous
Patient Initials: R.J.Age: 50 Years oldGender:50 Years oldSUBJECTIVE DATA: Chief Complaint (CC): The patient is complaining of nasal congestion, sneezing, rhinorrhea, and postnasal drainage, itchy nose, eyes, palate, and ears for 5 days. History of Present Illness (HPI): 50-year-old Caucasian male presents in the office with complains of nasal congestion, rhinorrhea, postnasal drainage, itchy nose, eyes, palate, and ears for 5 days. Patient states taking Mucinex OTC the past 2 nights to help him breathe while he sleeps with minimal relief.each principal symptom:1.Location: Ear, Nose, Throat2.Quality: n/a3.Quantity or severity: Severely itchy nose, throat and ears for 5 days4.Timing: it worsens at nighttime 5.Factors that have aggravated or relieved the symptom: mild relief after taking over the counter Mucinex
6.Associated manifestations: nasal congestion, rhinorrhea, postnasal drainage. itchy nose, eyes, palate, and ears7.Severity: n/aMedications: Mucinex OTC, hydrochlorothiazide, lisinoprilAllergies: shellfish. PollenPast Medical History (PMH): fracture femur at age 21 post Motor and vehicle accident, Asthma as a child ( has not had any symptoms since adolescence), Hypertension for 5 years. Past Surgical History (PSH): Right femur closed ORIF 29 years ago, hospitalized for 2 weeks post motor and vehicle accident 29 years ago.