WEEK HEENT (2)
· For your note this week, create an HEENT related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use an HEENT related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints. Examples: sore throat, ear ache, hearing loss, eye drainage, etc.).
· Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citations, and reference format. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).
· The ROS and physical exam in your document should be written up as they would be for a problem focused visit. The HEENT part of the physical exam write up should be a comprehensive write up.
Expectations
· Due: Friday 25th
Week 4 SOAP Note
United States University
Advanced Health and Physical Assessment Across the Lifespan MSN 572
Shannon Ripley
03/27/2021
SOAP
SUBJECTIVE:
ID: William Henry Ripley Jr, DOB 10/06/1950, age 70, white Caucasian male came to the clinic
alone for complaints of a “sore throat”. Bill is married to his wife for 42 years and lives in a
home independently. He works for the forest service and BLM. Patient appears to be a good
historian of his medical history and can answer all appropriate questions.
CC: “sore throat”
HISTORY OF PRESENT ILLNESS (HPI): Bill 70 year old male, Caucasian, came in for a “sore
throat”. Bill began to feel a sore throat a week ago with pain 3/10, it has increasingly gotten
worse to a sharp pain that is 7/10, he states it feels like he is swallowing glass. Bill has not been
eating solid food but has been drinking shakes for the last 2 days due to difficulty and pain while
swallowing. He states that drinking tea with lemon and honey or gargling salt water has helped
slightly, he also diffuses essential oils while he sleeps. Bill spiked a fever of 102 degrees
Fahrenheit last night, he took Tylenol 1000mg, PO x1 dose which decreased the fever to 98.6F.
Bill is not coughing, sneezing or have any nasal congestion. Bill does not have any seasonal
allergies and has not been around irritants such as smoke, pollen, molds, animal dander, or
indoor inhalants such as hair spray or aerosol products. He was recently at a birthday party and
around a friend who had a sore throat and later tested positive for streptococci group A. Bill
started feeling symptoms shortly after the birthday party and came in to get tested today. Last
physical was 12/2020. No recent immunization, denies getting the flu, pneumonia, shingles or
COVID vaccine. Last dental exam 11/2020. Denies any use of medications.
PAST MEDICAL HISTORY:
Tinnitus
Childhood illness: Patient had pneumonia as a young child (date unknown) and colon bacillus in
1965.
Chronic illness: Patient denies chronic illnesses.
Psychiatric history: patient denies psychiatric illnesses
PAST MEDICAL PROCEDURES:
Procedures: Tonsillectomy in 1958, laminectomy in 1970, removal of non-Hodgkin lymphoma
tumor in 07/1998, TURP in 11/2003, staple removal from chest in 8/2014 and fall of 2017. See’s
the dermatologist every 6 months to get pre-cancerous cells burned off.
Hospitalized: tumor removal in 07/1998 and during the laminectomy in 1970. No reactions to
anesthesia.
Last dental checkup 11/2020
MEDICATIONS:
Tylenol 1000mg, PO tabs, TID, as needed.
Daily
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