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S.O.A.P. Note: Assignment 3.3 EENT Documentation CASE ID# Subjective ObjectiveAssessment (diagnosis [primary and differential diagnosis])Plan (treatment, education, and follow up plan)Chief mplaintWhat brought you here today…(e.g. headache)Nasal congestionHistory ofPresentIllnessChronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph formOnset2 Weeks agoFrontal Sinus and maxillary sinus tenderness, headache, congestion2 weeksPressure, foul smellingTylenol for headache, Sudafed not workingCoughing and sore throat at night, ear pain, fatigueModerateLocationDurationCharacterAggravating/associatedfactorsRelieving factorsTemporal factors – otherthings going onSeverityPastMedicalHistoryAdult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medicationsAllergies: Aspirin, seasonalFrequent sinus infections-3 in the last 6 months, antibiotics 3 months ago, Nasal polyps removed by ENT MD 5 years ago then steroid shots