Coursework on Soap Notes for New Patient:
CC): Chief Complaint: Runny Nose
John O’Shea is a 32 year-old single white male. He presents a “Persistent head ache for 5 days” and “Sore throat for the last 2 to 3 days.” He also complains of “Right facial pain” which he aan over the counter “Tylenol” which gave him some relief but the running nose persisted.
History of present illness (HPI)
This 32 Year old man presents with a chief complaint of a runny nose for six days with accompanying head ache and sore throat. Patient has been experiencing severe headache for over 5 days on the sides of the head, right behind the eyes. The first onset of the pain was five days ago, after the pt retired home from work with a fleet of sneezes and runny nose. Pain was relieved with painkillers (ibuprofen) for the best part of the night only for the pt to wake up with a serious purulent drainage through the nasal passages. The drainage subsided by itself after the pt had taken breakfast and plenty of water only to appear again within a matter of hours. The runny nose is aggravated by any form of dust and coldness. Pt reports slight pain above cheekbones which he uses over the counter Tylenol which offers some relief to the pain. Pt would sometimes experience mild pain behind their eyes when they strain their sight or when they try to roll their eyes sideways. Running nose is intense during the night and in the mornings. Pt has experienced nausea especially during the day. With nausea, pt denies vomiting. For 2 days now, pt has had a bad sore throat accompanied by fever. Pt also denies skin rashes or hives, abdominal pains, pain above cheekbones, joint pains or coughing. The mild pain above the cheekbones subsided upon use of OTC Tylenol.
Pt reports Allergic rhinitis – Headache, diarrhea, frequented urination, sneezing, runny, stuffy nose, itchiness and difficult breathing. Food allergy for meat and fish – Generalized rashes, abdominal, diarrhea, skin itching, vomiting, cramps, swelling of soft tissues and the lips, and breathing complications. Denies allergies to latex and medication. The patient reports Acute Sinusitis.
Patient reports taking a dosage of 1 gram of Excedrin by mouth in duration of 5 to 6 hours up to 4 grams daily for 3 days, as it has been prescribed over the counter by a pharmacist. The patient has also been taking OTCs; pseudoephedrine nasal decongestant in form of tablets by mouth for 2 days. A total of 12 tablets had been taken so far following the pharmacist’s prescription of “a total of 2 tablets every 4 to 6 hours without exceeding a max of 8 tabs in 24 hrs. The patient had labels for both medications as noted. Pt denies any alternative or complementary treatment and Vitamins with similar specifics. The patient also reports oral tablets o Tylenol 6 tablets a day or the last 3 days.
PMH / PSH
Past Medical History (PMH): Pt reports history of hypothyroidism and HTN.
Pt also reports history of allergic rhinitis and Acute Sinusitis
Past Surgical History (PSH): Pt reports appendectomy, 1994; T&A, 2005.
Fam Hx (Family History)
Patient reports family history of HTN (Father diagnosed with HTN at the age of 39); CAD (mother with stent at age 43); hypothyroidism (sister). Denies family history of nasal allergies, and Migraine headache. Family history therefore is non-contributory and not useful for Chief Complaint (CC).
Soc Hx (Social History)
Work History: The patient has worked as a coal miner for 15 yrs. currently unemployed. Pt. single, lives alone in a rented flat house, never married.
Pt. reports a history of cigarette smoking 1 PPD for 15 YRS. Cessation 2009.
Pt. reports a history of consuming a pack of beer over the weekends for 15 yrs. Reports 1 beer weekly since March, 2011.
Pt. denies current use or history of illicit drugs.
ROS (Review of Systems)
CS (constitutional systems): Reports fever. Pt. denies weight loss, night sweats, lethargy/fatigue, and change in appetite, rash or itch.
Eyes: Report headache and pain beneath the eyes. Pt. denies visual changes, double vision, and
eye pain, floaters or blind spots (scotomas).
Neuro: Pt. denies weakness, dizziness, numbness or changes in mood, sleep or memory.
Ears, nose, mouth and throat (ENT): Reports runny nose, sinus pain, pain with swallowing, sore throat. Pt. denies stuffy or painful ears, toothache.
Cardiovascular: Pt. denies shortness of breath, loss of consciousness, oedema, chest pains or
Respiratory: Reports cough. Pt. denies haemoptysis, exercise intolerance, wheezing, sputum or
Trouble with breathing. States asthma is well-controlled. Lungs are not clear to auscultation and are not resonant to percussion.
Abd: Pt denies abdominal pain, constipation or diarrhea, N/V, or changes in stool pattern.
PE (Physical examination)
VS: P 85, B/P 127/82, HR 69, RR 18, height 6’5’’, Weight 182lb: pt is overweight, VS seems to be fine.
General: Alert & oriented x3, well nourished, well groomed, appropriate affect, in no acute distress (NAD), responds appropriately to interview and questions.
HEENT (head, eyes, ears, neck and throat): Normal
Skin: Dry and warm, no rashes or skin lesions, Lungs are CTA bilaterally.
Cardiovascular: Femoral pulses 2+, RRR having S1, S2, no murmurs, gallops or rubs.
Respiratory: Bilateral breath sounds (BBS) clear to auscultation, absence of adventitious breath noises.
Abdomen: BS present x 4 quads, normoactive, soft, non-distended, non-tender.
Neuro: Cranial Nerves Intact and functioning well.
Neck: Supple, no lmphadenopathy, no bruits, and trace evidence of thyromegaly.
Recent labs, X-ray, procedure and special test results
Ex: Na+ 136, K+ 4.2, BUN 9, Cr 0.8, glucose 82 (17/7/2011); Normal screening colonoscopy (10/05/2011); Abdominal ultrasound (18/6/2011) – single 10mm gallstone.
No supportive treatments. Pt advised to use hand wash regularly to avoid transmission of germs in future infections.
Tearing or runny nose not accounted for sinuses or cold symptoms.
Early hypothyroidism and HTN
Tympanic membranes pearly grey with a sharp reflex of light.
Right maxillary tenderness.
Preventive care should be observed. Pt should use hand wash and clean handkerchief all the time.
Patient should avoid alcohol or any other drugs when under medication. Pt should keep a clean environment within the house. Avoid dust and other allergens.
Always use prescription drugs and avoid over the counter medicines.
This is a plan based on all the symptomatic conditions presented by the patient.
Examine nasal secretions to determine allergic or infectious infections.
Repeat labs, X-ray and tests for Ex, K+, BUN, Cr & Gluc
Allergies: Give dosages for allergy antihistamines (Beclomethasone, cromolyn, or triamcinolone) + cough suppressants as well as oral decongestants (tablets). For antihistamines consider tabs or injection. Apply fluticasone nose spray allergy symptoms when noticed.
Runny Nose: Cough suppressants + decongestants to be taken by mouth following the right prescription. Treat with Amoxicillin 500 mg per day three times and a decongestants for a whole week. Follow up if symptoms persist.
Sore throat: mild antibiotics will be given to the patient.
Supportive treatment to pt such as taking plenty of fluids and having a good rest should also be incorporated. Advice pt regarding preventive measures for runny nose in adults e.g. frequent hand wash to cleanse germs which may cause cold flu, avoidance of nose, eye and mouth touch. Pt is advised to avoid allergens whenever possible. Provide pt with referrals and consultation information incase of any issues that may arise from worsening condition and reaction on medication; this could be allergy or intolerance. In this case, signed pharmacy student name and information. Pt follow up will have to take place in three days to assess the progress of the prescribed medication on the condition.
The patient is a 32 Year old man who presents with a chief complaint of a runny nose for six days with accompanying head ache and sore throat. Pt has been experiencing severe headache for over 5 days on the sides of the head, right behind the eyes.
Based on my assessment of the patient’s condition and response to the previous modes of treatment, my advice to the pt would be to take the prescribed doses of allergy antihistamines. I will also offer a cough suppressant and tablets for oral decongestion. For the case of the antihistamines there is a choice between tabs and injection. The pt is also advised to keep off alcohol and any other drugs not prescribed for the period of treatment. Pt must also ensure clean house environment free of dust and other allergens that might aggravate his situation. Pt advised to install window screens and vacuum clean house always. Pt should avoid outdoors in the woods when its sunny or windy.
I urge the pt to take plenty of fluids and rest. Avoid touching the nose, eyes and mouth as this could lead to infection with germs which cause cold flu. Alternatively you can be sure to use hand wash regularly to cleanse germs capable of causing such infections. The pt is also advised to seek medical follow up if symptoms persist. If the pt agrees to this mode of treatment, he is on a sure path to recovery.
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