PRAC 6568 Week 3 Assignment; Episodic Visit; HEENT Focused Soap Note

Episodic Visit: HEENT Focused Soap Note Lucia Mariolina Moutoux PRAC 6568 Synthesis in Advance Nursing Practice of Patients in Family Care Settings March 17, 2023 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. Current Medications: Multivitamins –women, OTC daily Allergies: NKA PMHx: Abnormal Pap smear of Cervix - 2013 Immunizations UTD. Flu vaccine 11/03/2022 Moderns 1st dose 12/28/2020 Moderna 2d dose 01/20/2021 Moderna Booster 10/28/2021 Surgical History: Cervical Biopsy w/loop electrode excision - 2013 Social and Substance HX: The patient lives in a single-family home with her two daughters, ages 6 and 14, and her husband of 17 years. She has been an accountant for 15 years. Reports she has never used or smoked tobacco products and reports occasional drinking during social events averaging 0.0-1.0 standard drinks per week. Denies any illicit drug use. Reports eating healthy meals, and exercising regularly by going to the gym 3 times a week, and engaging in 45 cardio each time. The household is equipped with smoke and CO2 detectors. The patient wears a seatbelt when in a motor vehicle. Family HX: Mother: Healthy and alive. Age 64 Father: HTN. Alive. Age 68 Maternal Grandmother: Deceased- unknown HX Maternal Grandfather: Alive, HTN. Age 88 Paternal Grandmother: Deceased- unknown HX Paternal Grandfather: Deceased- unknown HX Mental Hx: None Reported. Violence Hx: None Reported ROS Constitutional: Reports low-grade fever the first couple days of symptoms presentation and mild fatigue. No weight loss was reported. Denies chills. Denies any change in appetite. 1449069155494HEENT: Head: denies HA or dizziness. Eyes: Reports b/l clear watery discharge. Reports b/l eyes pruritus. Denies visual changes. Ears: denies ear pain, hearing loss, earache, or discharge. Nose: Reports nasal congestion, sneezing, clear running nose. Reports mild sinus pressure. Denies epistaxis. Throat: Reports pruritus of the oropharynx, and non-productive cough. Denies dental pain. Respiratory: Denies shortness of breath, dyspnea,