Assignment 3.1 Topic-Based SOAP Note.docx - Jessica...

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Jessica Phillips Assignment 3.1: Topic-Based SOAP Note Case ID# : S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan) Basic Information 55 yo well-developled male presents in office with c/o six days of sinus congestion and pressure, sore throat, headache, and a productive cough that is worse at night. Subjective History Patient states that he has had six days of sinus congestion and pressure, sore throat, headache, and a productive cough that is worse at night. Chief Complaint “six days of sinus congestion and pressure, sore throat, headache, and a productive cough that is worse at night” History of Present Illness Patient states that he has had six days of sinus congestion and pressure, sore throat, headache, and a productive cough that is worse at night. He states that his sinus pressure is over his frontal sinuses and especially between his eyes. He states that his pain is consistently a 5/10 with his sinus pressure. He states, “at times it is hard for me to breathe through my nose.” His sore throat began around the same time that his sinus pressure began or maybe a day later and worsens when he eats or drinks. When he eats or takes in fluids he rates his pain in his throat a 7/10 but, right now, not taking anything in orally and just sitting here it is a 3/10. He states that his productive cough also started around the same time as the sore throat. He states, “the mucous is clear but there is a lot of it especially at night.” The patient states that it has become a problem at work because when he tries to bend over and forward to clean his symptoms become “much worse”. The patient states that he has tried Ibuprofen 600mg PO every 6 hours as needed for the pain in
his throat and sinuses with minimal to moderate relief. He has also tried Tylenol which seems to help slightly better and takes 1000mg PO every 8 hours as needed as well. While he does say the Ibuprofen and Tylenol helped slightly he is no longer taking because “can’t you hurt your lungs and kidneys if you are on that stuff for too long?” He reports that the pain in his sinuses is “dull” for most of the day but intensifies when he lays down at night. Just sitting here he says, “the pain in my throat is also dull but when I try to eat or drink anything the pain is like glass on the back of my throat.” He does not recall coming into contact with anyone that has the same symptoms but does frequent the Cancer Center with his wife who is receiving chemotherapy for advanced breast cancer. He does report working in a hospital as a housekeeper where there are many sick people each day. Past Medical History Allergies: Peanuts, ACE inhibitors Past Medical History: Hypertension, Hyperlipidemia, seasonal allergies, anxiety Past Surgical History: appendectomy 1992, cholecystectomy 2000 Patient receives flu vaccine every year and plans to get at his place of employment in October.

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