Patient Information:
Initials, RB.
Age 50, Sex
Male, Race. Caucasian
Subjective
CC (chief complaint); nasal congestion and itchy eyes, nose, and palate for five days
HPI: Mr. Brown is a 50-year-old white male presenting with a complaint of nasal congestion, sneezing, rhinorrhea, nasal drainage, itchy nose, eyes, and palate for five days Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment. He states that he has been taking Mucinex for the past two nights with minimal relief. He denies a headache or pain.
Current Medications:
Mucinex OTC at bedtime
Hydralazine 25mg TID
Allergies: NKDA
-reports seasonal allergies
-denies environmental allergy
PMHx: has a history of hypertension. Denies other illnesses. Immunizations are up to date; he received a flu shot this season. He Received a Tetanus booster last year. Hospitalized in 2018 for left femur fracture repair from a fall. No other significant medical or surgical history Assessing the Head, Eyes, Ears, Nose, and Throat Episodic/Focused SOAP Note Case Study Assignment
Soc Hx: Mr. Brown lives in a one-story single-family home with his wife and three children. He has his master’s degree in business administration and works in a consulting firm where he has worked for 15 years. He is a former smoker, smoked cigarette from 17-38 years, and marijuana from the age of 18-30. He drinks socially about 1-2 drinks weekly. He states that he does not exercise but takes a walk around the neighborhood about three times weekly. He is a Christian and sometimes attends church on Sundays if he is not too tired. His wife is a beautician who enjoys making healthy meals for the family.
Include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx:
-Father has a history of hypertension and BPH
-Mother died at 78 from a stroke.
-Two sisters with no significant medical history
-Three children aged 15, 17, and 20 with no significant medical history.
-Maternal Grandparents died from a car accident when he was 18. He does not remember their ages at death.
-Paternal grandparents are deceased, but he doesn’t remember the ages and cause of death
ROS:
GENERAL: Alert and oriented to person, place, situation, and time. Denies recent weight changes. Denies fatigue, fever, chills, and weakness.
HEENT: Denies headache. Eyes are itchy and red. No visual loss, blurred vision, double vision or yellow sclerae. States that Ears are itchy, erythematic, and inflamed, denies hearing loss and discharge from the ear. The nose is itchy with sneezing, congestion, and runny nose. Clear nasal discharge. Reports sore throat. Denies difficulty swallowing.
SKIN: No changes in pigmentation. No discoloration, moles, rash, or itching. Denies any other skin abnormalities.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath or cough
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or discomfort. Reports regular daily bowel movements.
GENITOURINARY: Denies burning or pain on urination. Denies urinary tract infection.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain, fatigue, or stiffness.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis. Reports seasonal allergies.
Objective
Physical Exam:
General: Alert and oriented to person, place, situation, and time. Appears well groomed and nourished. Eyes are itchy and red. PERRLA
V/S: Temp: 97.9 degrees Fahrenheit, Pulse:72 beats per minute and regular. Resp:18 beats per minute, Blood Pressure: 141/76, weight: 185 pounds Height: 68 inches
HEENT: Head is normocephalic. Eyes are itchy
Order this paper