NURS 621 Assignment 3.1 Topic-Based SOAP Note. Case ID#:
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
55 yo well
...
NURS 621 Assignment 3.1 Topic-Based SOAP Note. Case ID#:
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
55 yo well-developled male presents in office with c/o six days of sinus congestion and pressure,
sore throat, headache, and a productive cough that is worse at night.
Subjective History
Patient states that he has had six days of sinus congestion and pressure, sore throat,
headache, and a productive cough that is worse at night.
Chief Complaint
“six days of sinus congestion and pressure, sore throat, headache, and a productive
cough that is worse at night”
History of Present Illness
Patient states that he has had six days of sinus congestion and pressure, sore throat, headache,
and a productive cough that is worse at night. He states that his sinus pressure is over his frontal
sinuses and especially between his eyes. He states that his pain is consistently a 5/10 with his
sinus pressure. He states, “at times it is hard for me to breathe through my nose.” His sore throat
began around the same time that his sinus pressure began or maybe a day later and worsens when
he eats or drinks. When he eats or takes in fluids he rates his pain in his throat a 7/10 but, right
now, not taking anything in orally and just sitting here it is a 3/10. He states that his productive
cough also started around the same time as the sore throat. He states, “the mucous is clear but
there is a lot of it especially at night.” The patient states that it has become a problem at work
because when he tries to bend over and forward to clean his symptoms become “much worse”.
The patient states that he has tried Ibuprofen 600mg PO every 6 hours as needed for the pain
[Show More]