see attached. last 2 sections only need completing.files (1)MSN_SOAP_Note_Vernon.docxMSN_SOAP_Note_Vernon.docx
Name: Vernon Hawthorne
Pt. Encounter Number: 1
Date: 10/3/23
Age: 55
Sex: Male
SUBJECTIVE
CC:
??runny nose, sore throat and cough?
HPI:
55 yo male presents to the office today with c/o runny nose, sore/scratchy throat and cough for 3 days. He reports the symptoms presented suddenly upon awakening 3 days ago. He denies any sick contacts or known exposure to COVID 19. Pt states the symptoms have been constant and are worsening with time. Denies aggravating factors. States he has tried Nyquil to treat the symptoms however, but it makes him groggy which he does not like. Reports he was treated at a clinic about 1 year ago for similar symptoms with a Zpack. Rates the severity of his symptoms 7/10 and states they are interfering with his work. He is requesting a Zpack for treatment but is agreeable to history and physical exam.
Medications:
No prescription medications.
Advil PRN .
Allergies:
NKDA
Past Medical History:
Denies
Chronic Illnesses/Major traumas:
Denies
Hospitalizations/Surgeries:
Denies
Preventive:
Vaccinations UTD
Family History
Denies significant family history. Both parents alive and well.
Social History
Pt has a Juris Doctor degree and practices law in his own firm which handles estate planning. He has been divorced twice, is not currently in a relationship and lives alone. He feels safe in his home. Reports alcohol use of one drink daily at night. Denies problem drinking. Denies tobacco use and drug use.
ROS Student to ask each of these questions to the patient: ??Have you had any?¦..?
General
Denies fever or fatigue.
Denies recent weight change.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies complaints
Respiratory
???? cough
Denies SOB. Denies wheezing
Eyes
Denies complaints
Gastrointestinal
Denies abdominal pain, denies nausea.
Ears
Denies complaints.
Genitourinary/Gynecological
Denies complaints
Not sexually active
Head/Nose/Mouth/Throat
???, ?, scratchy throat
Denies post nasal drip. Denies sinus pain or hoarseness.
Denies difficulty swallowing
Musculoskeletal
Denies complaints
Breast
Denies mass.
Neurological
Denies weakness. Denies syncope
Heme/Lymph/Endo
Denies swollen glands
Denies heat/cold intolerance.
Psychiatric
Denies depression anxiety related to current presentation
Denies SI
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Generally healthy appearing in no acute distress. Mood slightly irritated, requesting antibiotic prescription, easily redirected.
Skin
Skin is warm and dry, no rashes noted.
HEENT
PERLA. EOM intact. Conjunctiva normal.
Nasal mucosa with mild erythema and swelling. ???. Frontal and maxillary sinuses nontender.
Posterior pharynx erythematous. No exudate.
Bilateral tympanic membranes normal.
Cardiovascular
Heart with regular rate and rhythm, S1, S2 normal with no murmur, rub or gallop 3 pulses, no edema
Respiratory
Lung sounds clear bilaterally. Normal effort. Frequent cough present during assessment.
Gastrointestinal
Abdomen is soft, nontender. Active bowel sounds all quadrants. No organomegaly .
Breast
Not examined
Genitourinary
Not examined
Musculoskeletal
Observed normal ROM.
Neurological
Awake, alert and oriented x 4. Speech clear. Normal gait observed.
Psychiatric
Dressed appropriately. Interacting and answering questions appropriately.
Lab Tests
POC COVID 19 Antigen testing negative.
Assessment
· Include at least three differential diagnoses
· Provide rationale for each differential diagnosis
· Final diagnosis
· Pathophysiology of primary and rationale for choosing as final
Plan
· Medications *****include Tessalon and any others***
· Non-pharmacological recommendations
· Diagnostic tests
· Patient education
· Culture considerations
· Health promotion
· Referrals
· Follow up
MSN_SOAP_Note_Vernon.docx
Name: Vernon Hawthorne
Pt. Encounter Number: 1
Date: 10/3/23
Age: 55
Sex: Male
SUBJECTIVE
CC:
??runny nose, sore throat and cough?
HPI:
55 yo male presents to the office today with c/o runny nose, sore/scratchy throat and cough for 3 days. He reports the symptoms presented suddenly upon awakening 3 days ago. He denies any sick contacts or known exposure to COVID 19. Pt states the symptoms have been constant and are worsening with time. Denies aggravating factors. States he has tried Nyquil to treat the symptoms however, but it makes him groggy which he does not like. Reports he was treated at a clinic about 1 year ago for similar symptoms with a Zpack. Rates the severity of his symptoms 7/10 and states they are interfering with his work. He is requesting a Zpack for treatment but is agreeable to history and physical exam.
Medications:
No prescription medications.
Advil PRN .
Allergies:
NKDA
Past Medical History:
Denies
Chronic Illnesses/Major traumas:
Denies
Hospitalizations/Surgeries:
Denies
Preventive:
Vaccinations UTD
Family History
Denies significant family history. Both parents alive and well.
Social History
Pt has a Juris Doctor degree and practices law in his own firm which handles estate planning. He has been divorced twice, is not currently in a relationship and lives alone. He feels safe in his home. Reports alcohol use of one drink daily at night. Denies problem drinking. Denies tobacco use and drug use.
ROS Student to ask each of these questions to the patient: ??Have you had any?¦..?
General
Denies fever or fatigue.
Denies recent weight change.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies complaints
Respiratory
???? cough
Denies SOB. Denies wheezing
Eyes
Denies complaints
Gastrointestinal
Denies abdominal pain, denies nausea.
Ears
Denies complaints.
Genitourinary/Gynecological
Denies complaints
Not sexually active
Head/Nose/Mouth/Throat
???, ?, scratchy throat
Denies post nasal drip. Denies sinus pain or hoarseness.
Denies difficulty swallowing
Musculoskeletal
Denies complaints
Breast
Denies mass.
Neurological
Denies weakness. Denies syncope
Heme/Lymph/Endo
Denies swollen glands
Denies heat/cold intolerance.
Psychiatric
Denies depression anxiety related to current presentation
Denies SI
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Generally healthy appearing in no acute distress. Mood slightly irritated, requesting antibiotic prescription, easily redirected.
Skin
Skin is warm and dry, no rashes noted.
HEENT
PERLA. EOM intact. Conjunctiva normal.
Nasal mucosa with mild erythema and swelling. ???. Frontal and maxillary sinuses nontender.
Posterior pharynx erythematous. No exudate.
Bilateral tympanic membranes normal.
Cardiovascular
Heart with regular rate and rhythm, S1, S2 normal with no murmur, rub or gallop 3 pulses, no edema
Respiratory
Lung sounds clear bilaterally. Normal effort. Frequent cough present during assessment.
Gastrointestinal
Abdomen is soft, nontender. Active bowel sounds all quadrants. No organomegaly .
Breast
Not examined
Genitourinary
Not examined
Musculoskeletal
Observed normal ROM.
Neurological
Awake, alert and oriented x 4. Speech clear. Normal gait observed.
Psychiatric
Dressed appropriately. Interacting and answering questions appropriately.
Lab Tests
POC COVID 19 Antigen testing negative.
Assessment
· Include at least three differential diagnoses
· Provide rationale for each differential diagnosis
· Final diagnosis
· Pathophysiology of primary and rationale for choosing as final
Plan
· Medications *****include Tessalon and any others***
· Non-pharmacological recommendations
· Diagnostic tests
· Patient education
· Culture considerations
· Health promotion
· Referrals
· Follow up
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