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….