Tara Ricci NU 650 HEENT Week 6 Soap Note
Overview
▪ P.R, 9/25/11, Single, white
▪ Source is from patient and mother which is reliable
▪ Chief Complaint-HEENT exam for sneezing and itchy watery eyes
▪ History of present illness- pt presents with her mother for itchy and watery eyes...
Overview
▪
P.R, 9/25/11, Single, white
▪
Source is from patient and mother which is reliable
▪
Chief Complaint-HEENT exam for sneezing and itchy watery eyes
▪
History of present illness- pt presents with her mother for itchy and
watery eyes. She reports sneezing multiple times daily and nasal
congestion
• Symptom analysis
o Onset- It has been intermittent for the last 2 weeks
o Location- Nasal congestion, both eyes get watery
o Duration- 2 weeks
o Characteristics-It is worse in the morning. She
reports “I wake up with a stuffy nose and it
makes my eyes itchy and watery”
o Associated/aggravating factors- cold weather makes
it worse
o Relieving factors- none
o Treatment- Has been using Zyrtec which helps
sometimes but feels it’s not working like it used
to.
o Review of Systems
▪ General: Well appearing. Denies any weight loss or gain.
Reports adequate sleep and balanced diet. Denies any weakness
▪ Head: Denies headaches and any history of head injury.
No dizziness
▪ Eyes: No difficulty with vision, some watering and itching of
both eyes, no dryness, pain, redness. Some clear watery drainage
from both eyes. Denies use of glasses
▪ Ears: Denies any problems with hearing or use of hearing aids. No
pain, vertigo, tinnitus, discharge. History of otitis media: 3/2014,
10/2016
▪ Nose and sinus: Deny any frequent colds or sinus infections.
Reports intermittent nasal congestion and sneezing. Denies sinus
pain and nose bleeds
▪ Mouth and throat: Teeth and gums are in good condition, denies
bleeding gums or sore throat. Last dental exam 5/2020. Denies any
change in taste or swallowing
▪ Neck: Denies any lumps or swollen glands, goiter, pain,
or stiffness
o Functional assessment
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