SINUS SOAP week 3 (4).docx - S.O.A.P Note Template History...

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S.O.A.P. Note Template Subjective ObjectiveAssessment (diagnosis [primary and differential diagnosis])Plan (treatment, education, and follow up plan)Chief mplaintWhat brought you here today…(eg. headache)“Sinus congestion, cough, sore throat”History ofPresentIllnessChronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph formOnsetMr. Smith is a 55 year old Caucasian male who presents with sinus congestion/pressure, sore throat, headache, and a productive cough, and yellow drainage. These symptoms started roughly 10 days ago. His sinus congestion/pressure is located “across his nose and between his eyebrows and at his cheek bones” and causes him about a 4/10 on the pain scale. His sore throat is constant, and he rate a 6/10 on scale 0-10, he stated is like a knife pain. His cough is the same at night and during the day. His headache is in the front of his head between his eyebrows and forehead is rated at a 5/10 at its worst it is a constant throbbing pain. He has taken ibuprofen which he states relieves his headache and sore throat but does not help his other symptoms he is taking 300mg 3 times a day. His throat pain is more like a sharp pain, that gets worse when he swallows, he has been having poor appetite due to the pain. The patient denies having contact withanyone who has similar symptoms, but he has had multiple trips to the hospital’s “infusion center” as his wifeis receiving chemotherapy for progressive breast cancer. He stated he has not had any dizziness, earache, nausea, or vomiting. He has not been sleeping well due to wife being sick and constant pain. Denied Fever, chills, he has been more tired than normal. He does not smoke and denied any rash. He stated he has been a little sob while he goes up and down the stairs fast, but he is able to catch his breath fast. He has not had any difficulty hearing, no change in vison. Patient stated he has had sinus infection before and was treated with Augmentin does not recall the dosage and symptoms were relived in a couple days. LocationDurationCharacterAggravating/associatedfactorsRelieving factorsTemporal factors – otherthings going onSeverityPastMedicalHistoryAdult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medicationsAdult illness: History of sinus infections. Three times in the past six months, nasal polyps.

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