PRAC 6568 Week 3 Assignment; Episodic Visit; HEENT Focused Soap Note
- $20.00
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Patient Information: CG, 39, Female, White S.
CC: “Intermittent runny nose with watery eyes, and itchy throat x 10 days”
HPI: This is a 39 y/o Caucasian female who presents to the office with c/o intermittent clear runny nose for the past 10 days. Reports associated symptoms of mild fatigue, intermittent pruritus of the nose, and oropharynx with non-productive cough, mild sinus pressure, itchy watery eyes, and occasional sneezing. The patient believes experiencing low-grade fever the first couple of days but never measure it. Has tried Tylenol cold and flu symptoms OTC the first couple of days with very mild relief. Has tried and continues to use Afrin OTC which has provided relief with sneezing and rhinorrhea. However, she continues to experience severe nasal congestion if “not worse”. Reports symptoms are worse when exposed to the outdoors but she is not sure about it. The severity of congestion symptoms is rated 7/10 and described as pressure over the frontal sinuses and “nose” Reports tested negative for Covid at home multiple times and denies any known exposure to Covid or anyone else with similar symptoms. Denies HX of asthma or eczema. Not sure if she has had seasonal allergies vs. “colds” in the past……….. Continue
