URI SOAP NOTE.docx - 1 Chief Complaint Sinus congestion...

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1 Chief Complaint Sinus congestion, cough, sore throat History of Present Illness A pleasant 55-year-old male presents to the clinic with complains of six days of sinus congestion and pressure, sore throat, headache, and a productive cough that is worse at night. Patient states he had been fighting a cold two weeks ago which improved and then relapsed. Patient reports a productive cough with clear sputum. Patient reports 7/10 achy headache; and 8/10 dull pain to his throat – “hurts when I swallow.” Patient has been taking Tylenol for pain and Sudafed for the nasal congestion. Denies any nausea, vomiting, chills, fever or night sweats. He is currently taking care of his wife who is undergoing chemotherapy for advanced breast cancer. Past Medical History Past medical history: NKDA, Seasonal Allergies Past surgical history: Left inguinal hernia repair 2014 Patient is up to date on his influenza and tetanus vaccines. Patient does not qualify at this time for a pneumonia vaccine. Patient received all of his childhood immunizations. Patient does not have any known drug allergies. Has seasonal allergies. Patient currently takes: Simvastatin 10 mg daily at night; Metoprolol 25mg daily; Zyrtec 10mg PRN Family History Mother: 72 years old; hyperlipidemia, hypothyroidism. Father: 82 years old; HTN, HDL, Parkinson’s disease Sister: 39 years old; IBS Personal/Social History Patient is a Senior Systems Administrator and works at L3 Harris. Patient is active with his family and at church. Patient is currently taking care of his wife who has advanced breast cancer. Patient states he has a strong support system that help care for his wife. Non-smoker. Denies exposure to second-hand smoke. Denies the use of recreational drugs. Occasional drinker. Patient walks about 10 miles per week and states he “watches what he eats.” Reports he’s trying to stay healthy to be able to take care of his wife. Review of Systems General: Negative for fatigue, fever, chills, night sweats. Hair, Skin, & Nails: Negative for rashes or skin lesions Head: Positive for current headache but no history of head injury or acute visual changes.

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