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MSN 572 HEENT Soap Note
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MSN 572 HEENT Soap Note
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Running Head: HEENT SOAP NOTE 1MSN 572 HEENT Soap Note
United States University
MSN 572
Advanced Health and Physical Assessment Across the
Lifespan
, Running Head: HEENT SOAP NOTE 2
Youtube Video Link: https://youtu.be/u2cMNKN9c7A
ID: Patient OC , born 1/1/2000, 20 year old African Male Adult, a reliable historian, arrived alone to the clinic.
CC: “I have severe pain to my lower right back tooth, its throbbing and I cannot wait until my scheduled dentist
appointment in two days.”
HPI : OC, a 20 year old African Male, is here for a sick visit. OP complains of tooth pain on a scale of 10/10 to
his right lower posterior tooth. OC states that the pain started two days ago and is progressively getting worse.
Pain is located near tooth number 31 -30. OC states that the pain is sharp, throbbing and sensitive to mechanical
movement and also heat and cold temperatures. OC states that the duration is “throughout the day”. OC states
that the tooth pain radiates right jaw to right ear. OC has tried taking pain medications for relief. OC states that
the medications taken are ineffective, and has not tried another pain medication for the tooth pain. OC states
that he doesn’t recall the medication nor the dose that he initially tried. OC reports chewing and heat and cold
foods as aggravating factors. OC states that he does not experience fever, nausea, chest pain, or shortness of
breath. OC tried gargling his mouth with mouthwash three times a day to help with the pain but it has not
worked. He also reports no changes in his regular diet. He states that he usually sleeps 7-8 hours a night, but
since two days ago he has unable to sleep well due to the pain. OC reports that there are no additional stressors
such as recent dental trauma, anxiety or new life changes. Currently there are no relieving factors. OC has no
other complaints at this time. OC states he is in overall great physical health and his last visit was 09/14/20 for a
wellness exam. OC has had most normal health screenings as advised, and his last cholesterol levels were done
on 01/14/2020 and normal. OC is a sophomore at the Junior College downtown, and lives alone.
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