NRP 531 WEEK 5 SOAP NOTE - NRP 531 Patient: Harold James, Otitis Externa and TIA.

Episodic SOAP Note: Harold James Name NRP 531 Date Professor DOS: 4/29/2019 ID: Harold James (M) DOB: 6/28/47 (72) CC: Otitis Externa and TIA Subjective HPI: Harold James is a 72-year-old African American male deemed a poor historian presenting with complaints of otitis externa and TIA. Patient is accompanied by his daughter who provides history. Harold’s daughter who talks with the patient daily reports that she noticed that her father has become increasingly forgetful and does not recall conversations they had earlier in the day and is concerned about memory loss. The patient’s daughter states she witnessed Harold have an episode in which he stared at her and of slurred speech lasting 30 seconds a few days ago. Harold’s daughter denies history of seizures, recent surgery, previous stroke or TIA’s, systemic or central nervous system infections and migraines. Harold also complains of worsening pain in his left ear over the past week which he rates 10/10 severity which he reports he cannot lay on the left side due to pain and denies loss of hearing. Harold’s daughter noticed the opening of the left ear to be swollen with yellowish-tan drainage which she accounts for his aggressive use of cotton swabs. Harold’s daughter reports that he has not been compliant with medications since the weekly medication container has days that have been skipped. Harold verbalizes to his daughter that he tries to remember to take them. Harold denies chest pain, shortness of breath, urinary complaints, abdominal pain and rashes.