HEENT Focused SOAP Note Assignment
HEENT Focused SOAP Note Assignment
CC: “Left ear pain” for the past two weeks accompanying with fevers. HPI: 42 y. o., Female patient presenting for evaluation of left mild ear pain that started two weeks ago. Patient reports left ear pain is constant and pressure like and rates it 4 (scale 0-10). Patient denies drainage, throat, head and sinus pain. Patients left sided ear pain is accompanied by fever of 99.5 – 101.2 F, nasal congestion, clear drainage, fatigue. Treatment prior to arrival includes Tylenol 650 Mg PO Q6hrs for pain and fever.
Allergies: Seasonal
Current Medications:
Omeprazole 40 mg PO daily
Wellbutrin XL 300 mg PO daily
Alprazolam 1 mg PO daily PRN PMH: GERD, depression, anxiety. Vaccinations up to date, Tdap 10/17 FH: Mother is living, Father is living. No siblings. No history of premature cardiovascular disease in first degree relatives. SH : Denies tobacco abuse, denies alcohol use; married for 15 years, no kids.
ROS:
ORDER CUSTOM, PLAGIARISM-FREE PAPER
General: Reports occasional fevers (99.8-102.3F). Reports fatigue and lack of energy.
Neurological: No headaches, no dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
HEENT: Eyes: No visual loss, blurred vision, doubles vision or yellow sclera. Reports left ear pain that started a week ago and reports pain is a 4 (0-10), Nose, Throat: No hearing loss, sneezing, moderate congestion, runny nose, no sore throat.
Skin: No rash or itching.
Cardiovascular: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
Respiratory: No shortness of breath, cough or sputum.
Gastrointestinal: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
Genitourinary: No burning on urination. Last menstrual period 03/5/2021.
Musculoskeletal: No muscle, back pain, joint pain or stiffness.
Psychiatric: History of depression or anxiety.
O.
Vital Signs: Temp 99.6 F, HR 67, RR 17, BP 128/73, O2 Sat 97%
General: Alert, oriented and cooperative.
HEENT: Head is normocephalic and atraumatic. Pupils equally round, 4 mm, reactive to light and accommodation, sclera translucent, conjunctiva pink and moist. Tympanic membranes are pearly gray with no bulging or exudates noted. Nasal mucosa is moist and pink with clear drainage present.
Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or supraclavicular areas.
Skin: Normal in appearance, texture, and temperature.
Cardiovascular: Regular rate and rhythm S1/S2. No gallop, murmur or other adventitious sounds noted.
Respiratory: Lungs are clear to auscultation and percussion bilaterally.
Gastrointestinal: No tenderness with palpation, Active BS X 4. HEENT Focused SOAP Note Assignment
Genitourinary: Deferred.
Musculoskeletal: Normal assessment.
Otoscopic exam revealed no abnormal findings, no redness, no budging and no drainage in both ears.
Consultation: Referral was send to an ENT specialist for further work up.