NURS 6531 Week 3 assignment:
HEENT Episodic SOAP Note
Patient Information:
LG, 72-Year-Old, Hispanic Male
CC: I have a cough and I have green yellow phlegm
HPI: Patient LG present today to the clinic for a follow up on labs, but is complaining
about a persistent productive cough that occurred about 3 days ago. Patient states that
he has green/yellow phlegm that comes out when he coughs and experiencing possible
fever, he did not take his temperature but felt hot and took a Tylenol last night for his
possible fever. Patient denies SOB and Chest pain.
Current Medications: Multi Vitamin PO One a day, Tylenol 650mg PO Q 6hrs for fever,
Asprin 81mg PO daily, Gabapentin 300mg PO TID, Metoprolol 12.5 PO daily
Allergies: NKDA, no food allergies,
PMHx: Flu Vaccine October 2018, Pneumonia Vaccine November 2016, No previous
hospitalizations or surgeries
Soc Hx: Lives with his wife. Both are retired and enjoy taking trips to visit their children
and grandchildren. Patient dines smoking, alcohol and illicit drug use. Patient is sexually
active in a monogamous relationship for 37 years.
Fam Hx: Patients father died of a stroke in his 80’s, Patient mother deceased from heart
attack
ROS:
GENERAL: Patient denies weight loss, patient reports fever or feeling hot, productive
cough
HEAD: Patient denies head ache, head injury, dizziness
EENT: Eyes: Patient has no visual loss, blurred vision, double vision or yellow sclerae.
Ears: Patient denies hearing changes or difficulty hearing Nose: Patient denies
bleeding, nose injuries, and patient does report congestion and a runny nose. Patient
report sore throat and productive cough for 3 days.
SKIN: Patient denies rash or itching.
, CARDIOVASCULAR: Patient denies chest pain, chest pressure or chest discomfort.
Denies palpitations or edema.
RESPIRATORY: Patient denies shortness of breath. Patient reports cough and
green/yellow phlegmn.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. Denies
abdominal pain or bloody stool.
GENITOURINARY: Patient Denies burning on urination.
NEUROLOGICAL: Patient denies headache, dizziness, syncope, paralysis, ataxia,
numbness or tingling in the extremities. Denies change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, unexpected bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ALLERGIES: No history of asthma, hives, eczema or rhinitis. Reports seasonal
allergies
O.
Physical exam:
Vital signs: HR: 82 BP:128/70 Temp: 100.1 Resp: 20 O2 sat: 96% on RA Ht: 5”7” Wt:
210lbs
General: Patient LG is awake, alert, well groomed, appears to have good hygiene,
answers questions appropriately, appropriate mood and affect.
HEENT: cranium is atraumatic, normocephalic. Pupils are equal, round and reactive to
light and accommodation. Sclera are nonicteric, moist mucosal membranes.
Neck: Supple no JVD, no lumps, bumps or thyromegaly.
Lungs: Currently clear bilaterally throughout all lung fields with some congestion heard
with coughing.
Heart: Heart rate is currently in the 80’s sinus rhythm, S1 S2 heart tones heard no
murmur heard on auscultation.
HEENT Episodic SOAP Note
Patient Information:
LG, 72-Year-Old, Hispanic Male
CC: I have a cough and I have green yellow phlegm
HPI: Patient LG present today to the clinic for a follow up on labs, but is complaining
about a persistent productive cough that occurred about 3 days ago. Patient states that
he has green/yellow phlegm that comes out when he coughs and experiencing possible
fever, he did not take his temperature but felt hot and took a Tylenol last night for his
possible fever. Patient denies SOB and Chest pain.
Current Medications: Multi Vitamin PO One a day, Tylenol 650mg PO Q 6hrs for fever,
Asprin 81mg PO daily, Gabapentin 300mg PO TID, Metoprolol 12.5 PO daily
Allergies: NKDA, no food allergies,
PMHx: Flu Vaccine October 2018, Pneumonia Vaccine November 2016, No previous
hospitalizations or surgeries
Soc Hx: Lives with his wife. Both are retired and enjoy taking trips to visit their children
and grandchildren. Patient dines smoking, alcohol and illicit drug use. Patient is sexually
active in a monogamous relationship for 37 years.
Fam Hx: Patients father died of a stroke in his 80’s, Patient mother deceased from heart
attack
ROS:
GENERAL: Patient denies weight loss, patient reports fever or feeling hot, productive
cough
HEAD: Patient denies head ache, head injury, dizziness
EENT: Eyes: Patient has no visual loss, blurred vision, double vision or yellow sclerae.
Ears: Patient denies hearing changes or difficulty hearing Nose: Patient denies
bleeding, nose injuries, and patient does report congestion and a runny nose. Patient
report sore throat and productive cough for 3 days.
SKIN: Patient denies rash or itching.
, CARDIOVASCULAR: Patient denies chest pain, chest pressure or chest discomfort.
Denies palpitations or edema.
RESPIRATORY: Patient denies shortness of breath. Patient reports cough and
green/yellow phlegmn.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. Denies
abdominal pain or bloody stool.
GENITOURINARY: Patient Denies burning on urination.
NEUROLOGICAL: Patient denies headache, dizziness, syncope, paralysis, ataxia,
numbness or tingling in the extremities. Denies change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, unexpected bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ALLERGIES: No history of asthma, hives, eczema or rhinitis. Reports seasonal
allergies
O.
Physical exam:
Vital signs: HR: 82 BP:128/70 Temp: 100.1 Resp: 20 O2 sat: 96% on RA Ht: 5”7” Wt:
210lbs
General: Patient LG is awake, alert, well groomed, appears to have good hygiene,
answers questions appropriately, appropriate mood and affect.
HEENT: cranium is atraumatic, normocephalic. Pupils are equal, round and reactive to
light and accommodation. Sclera are nonicteric, moist mucosal membranes.
Neck: Supple no JVD, no lumps, bumps or thyromegaly.
Lungs: Currently clear bilaterally throughout all lung fields with some congestion heard
with coughing.
Heart: Heart rate is currently in the 80’s sinus rhythm, S1 S2 heart tones heard no
murmur heard on auscultation.
