COURSE
NRNP 6540 Advanced Practice Care of Older Adults
Week 4 Assignment; Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders
Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders
Complete the Focused SOAP Note Template provided for the patient in the case study. See the Week 4 Assignment area for complete instructions.
By Day 7 Submit your Assignment.
SOLUTION
Patient Initial: AC Age: 76 Gender: Female
SUBJECTIVE DATA
CHIEF COMPLAINT (CC): Persistent runny rose for 3-week duration, associated clearing of throat and nasal congestion on awakening in the morning.
HISTORY OF PRESENT ILLNESS (HPI): Patient AC, a 76-year-old Caucasian female presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
VITAL SIGNS: | Temperature: | 98.6 |
Blood Pressure: | 130/84 | |
Heart Rate: | 78 | |
Respiratory Rate: | 20 |
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