SOAP_NoteTemplate MAGADA W3 EENT.docx - Submitted by...

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Submitted by Darlene Magada (NURS 612: Week 3 ENT) Date: Jan. 28, 2021 S.O.A.P. Note Template CASE ID# ____________________________ S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan) Chief mplaint What brought you here today…(eg. headache) Sinus pressure and terrible headache for the past 2 weeks. History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Middle age Caucasian female came to the clinic with a chief complain of sinus pressure, accompanied by terrible headache started 2 weeks ago. She reported of having three sinus infection in the last six months and was on antibiotics three months ago for the same reason. She reported that the pressure pain is located on her frontal and maxillary sinuses and she also experiencing right anterior ear pain aggravated by swallowing and described as tender and can hear popping sound. She added that she has nasal congestions and can smell a bit the secretions. She reported that she sometimes coughs at night which is worse when laying down and sore throat intermittently. She believed that she is having another sinus infection because of the same symptoms before except the ear pain. She denies difficulty of breathing, wheezing, chest pain, fever, chills, sweats, and joint pain. The patient takes over the counter (OTC) Tylenol for headache and OTC Sudafed but reported did not help her nasal congestion. She verbalized that she has allergy to aspirin and has seasonal allergies but does not take any medication for thus and have never seen allergologist. She stated that she had ENT consult five years ago for nasal polyp removal and was prescribed with steroid injections every 6 months but did not go back for follow up. Location Duration Character Aggravating/associated factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications Adult illness: Recurrent sinus infection (3x in the last 6 months) Childhood illness: not addressed Immunizations: not addressed Surgeries: nasal polyp removal 5 years ago Allergies: Aspiring and seasonal allergies Family History Include Parents, siblings; grandparents if applicable/known, cause of death, Not addressed Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known Not addressed Review of Systems General: Alert and oriented; able to provide history; no fever, chills, or sweats. Reported fatigue due to headache Hair, Skin, & Nails: Not mentioned Head: Symmetric; positive for headache and sinus pressure (frontal and maxillary sinuses) Neck: Symmetric; negative for lymph node involvement Eyes: Normal; negative for vision changes, drainage, or pain Ears:

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