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Week 5 Discussion Post Episodic/Focused SOAP Note Template

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Week 5 Discussion Post Episodic/Focused SOAP Note Template Patient Information: L., 20, F, Caucasian SUBJECTIVE. CC: “I have been having sore throat for three days, and I also have decreased... appetite, headache, and pain with swallowing.” HPI: Ms. L is a 20-year-old female college student who presents with sore throat for three days, with additional decreased appetite, headache, and pain with swallowing. She recounts that similar “flu-like” symptoms recently affecting multiple students on campus. Ms. L also noted runny nose and a slight hoarseness in her voice but doesn't sound congested. She took Tylenol and Chloraseptic lozenges, but did little for relief. Location: throat Onset: 3 days ago Character: throat is sore Associated signs and symptoms: decreased appetite, headache, and pain with swallowing. Timing: constant Exacerbating/ relieving factors: light bothers eyes, Tylenol makes it tolerable but not completely better. Severity: 8/10 pain scale Problem-Specific Questions: Have you been coughing? Any drainage or phlegm? Is it productive, if so how much? What is the color of the phlegm? Have you been running a fever or exhibiting chills? Are you taking any medications for this? Are they helping? Are you having any pain or pressure in your face, head, or sinuses? Have you recently had a head injury? Any nasal bleeding noted? Do you smoke or have you been around anyone who smokes? Do you experience gastroesophageal reflux or heartburn? Does it hurt to swallow solids, liquids, or both? Do you feel like something is stuck in your throat? Do you cough or choke when swallowing? Do you have any changes in your appetite? Did it start with the onset of your sore throat? Any changes in your weight? Did you lose or gain weight? What have you eaten in the last twenty-four hours? Have you had any nausea or vomiting? Current Medications: Multivitamins 1 tablet daily; and Blisovi Fe 1/20 1 tab daily Allergies: Penicillin (Hives) PMHx: ……………………………..continued………………………… [Show More]

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