HA2
1 EPISODIC/FOCUSED SOAP NOTE TEMPLATE
Patient Information:
Initials: CTL Age: 32-year-old Sex: Female S.
2 CC (CHIEF COMPLAINT): 3 “FEELING TIRED AND HAIR FALLING OUT.” HPI: 4 CTL WHO IS ALERT AND ORIENTED COMES TO THE CLINIC WITH A THREE DAY OF TIREDNESS AND HAIR FALLING OUT. 2 SHE HAS GAINED 30 POUNDS LAST YEAR AND NOTICED SOME REDUCTION IN THE APPETITE. ON THE REVIEW OF THE SYSTEM (ROS), CTL REPORTS NOT SLEEPING WELL AND IS FEELING COLDER ALL THE TIME. THE PATIENT STILL ENJOYS HOBBIES AND IS NOT CONVINCED THAT SHE IS DEPRESSED. the patient also complaints about the itching eye, ears, and nose as well as the palate. The observation reveals, the patient had used her fingers to touch as well as rub the bridge in her nose ad she is nose bleeding to. 1 THE PATIENT ALSO REPORTS COMPLAINTS OF NASAL CONGESTION, POSTNASAL DRAINAGE, SLEEPING DIFFICULTIES, AND RHINORRHEA. She has been on Mucinex to help with the breathing.
Current Medications: Mucinex OTC
Allergies: 5 NO KNOWN DRUG ALLERGIES.
PMHx: the patient immunization is up-to-date and was immunized for tetanus last year December Soc Hx: she is an account employed at the neighborhood school. The patient does not smoke or take any alcohol. She spends her weekends with friends and vising family members Fam Hx: Mother and father alive at 60 and 75 years old respectively. Father on medication for hypertension that was diagnosed 20 years ago. The mother is alive.
ROS:
GENERAL: 1 SHE REPORTS SLEEPING WELL, ADMITS WEIGHT LOSS, DENIES FEVER AND CHILLS, WEAKNESS OR FATIGUE.
HEENT: Eyes: 2 DENIES CHANGES IN THE VISION. Admits itchiness and watery eyes. 2 WEARING GLASSES FOR FARSIGHTEDNESS. 6 EARS, NOSE, THROAT: normal and bilateral, no ear infection, denies hearing. Admits congestion of the nose and sneezing; 6 DENIES PAIN, MASSES, OR LYMPHADENOPATHY.
SKIN: no laceration, rashes, itching, and bruises.
CARDIOVASCULAR: denies paining chest, palpitation, chest pain, history of arrhythmia RESPIRATORY: 7 DENIES SHORTNESS OF BREATH, COUGHING OR PRODUCTION OF SPUTUM, LUNG CLEARANCES.
GASTROINTESTINAL: 8 DENIES CHANGES IN THE BOWEL HABITS, NAUSEA, VOMITING OR DIARRHEA. Denies pain of the abdomen or bloody stool.
GENITOURINARY: denies dysuria, incontinence, frequency or urge of urination, Last menstrual period was 06/20/2021.
NEUROLOGICAL: 2 DENIES HEADACHE, SEIZURES, MIGRAINES, OR FALLS.
MUSCULOSKELETAL: 9 HAS HISTORY OF TRAUMA, DENIES MUSCLE, BACK PAIN, JOINT PAIN OR STIFFNESS.
HEMATOLOGIC: 10 DENIES ANEMIA, BLEEDING OR BRUISES.
LYMPHATICS: reports no enlarged nodes and denies history of splenectomy.
PSYCHIATRIC: 11 DENIES DEPRESSION OR ANXIETY. Normal affect.
ENDOCRINOLOGIC: 9 DENIES SWEATING, COLDNESS OR HEAT INTOLERANCE.
ALLERGIES: 12 DENIES HAVING HAD ASTHMA, HIVES, ECZEMA OR RHINITIS.
O.
Physical exam:
Vital Signs: the Pulse-75 beats/min; Blood Pressure-120/75 mmHg; temperature-97.4; Weight-210;
3
Height 6’1’’ General: 2 THE PATIENT APPEARS CLEAN AND FATIGUED; 13 SHE IS ALERT AND ORIENTED ×3
HEENT: PERRLA, wearing glasses for reading, Reports the lack of smell and taste. 2 NORMAL TONSILS, DENIES ABNORMALITIES OF THE ORAL OR ERYTHEMATOUS OF THE THROAT. Denies change in the vision.
Neck: no tenderness on palpitation.
14 CHEST OR LUNGS: there is bilateral CTA
2 HEART/PERIPHERAL VASCULAR: 15 THERE IS STRONGER AND REGULAR PULSE IN THE FOUR EXTREMITIES. 2 NO MURMUR OR IRREGULAR HEARTBEAT
Abdomen: 2 HYPERACTIVE BOWEL SOUNDS IN ALL THE FOUR QUADRANTS
Skin: 2 PALE, WARM, DRY
Musculoskeletal: 2 NO ABNORMALITIES NOTED
A.
Differential Diagnoses.
Acute Sinusitis: the bacterial infection of the paranasal sinus and the symptoms include the loss of smell, pain of the face, postnatal drip, anterior discharge, and the obstruction of the nose
Chronic Sinusitis: this is an inflammation of the nasal cavities and the passages that occurs for eight weeks without treatment. The key symptoms of this condition include breathing difficulties due to the blockage of the nose by the mucus that building in the nose. There is also painful or swelling of the eyes that results in headache and facial pain.
Allergic rhinitis: the exposure of the body to allergens leads to hay fever or allergic rhinitis that occurs in the form of inflammatory response. The condition is characterized by symptoms such as running nose, sneezing, itchy, and watery eyes. A person responds by rubbing the nose using index finger. There is also dark coloring around the eye that is caused by nasal congestion or vasodilation.
Rhinovirus: this disease is characterized with sinus infections, sore throat, and the common cold. 4 THERE ARE ALSO SYMPTOMS OF SNEEZING, CONGESTION, BREATHING DIFFICULTIES, RUNNING NOSE, AND COUGHING THAT IS ACCOMPANIED BY THE LOSS OF APPETITE, WEAKNESS, HEADACHE, FATIGUE, AND THE MUSCLE ACHES.
P.
References
Penza, K. S., Murray, M. A., Myers, J. F., Furst, J. W., & Pecina, J. L. (2021). Management of acute sinusitis via e-visit. Telemedicine and e-Health, 27(5), 532-536.
Petersen, S. W. (2016). 2 ADVANCED HEALTH ASSESSMENT AND DIAGNOSTIC REASONING. JONES & BARTLETT LEARNING.
Citations (15/15)
· 1Another student's paper
· 2Another student's paper
· 3Another student's paper
· 4Another student's paper
· 5Another student's paper
· 6https://www.academicscope.com/2-response-to-advanced-health-assessment/
· 7Another student's paper
· 8Another student's paper
· 9Another student's paper
· 10Another student's paper
· 11https://www.academicscope.com/clinical-decision-making/
· 12Another student's paper
· 13Another student's paper
· 14Another student's paper
· 15Another student's paper