NR 511 WEEK 2 SNAPPS ORAL PRESENTATION TEMPLATE GRADED A VERIFIED 100% CORRECT

CC Nasal congestion and headache HPI statement using OLDCARTS data SA is a 46-year-old Caucasian female that presents to the office with complaints of nasal congestion with drainage, headache, right ear pain, and intermittent cough. Onset: 3 days ago Location: nose, head, face, and right ear Duration: nasal congestion and pain has been persistent and constant for the past 3 days Characteristics: nasal congestion is mild to moderate alternating with clear to yellow drainage, headache is dull, right ear pain is reported as dull with a significant amount of pressure, and intermittent cough. Reports pain 2 out of 10 Aggravating factors: more severe when bending or leaning over Relieving factors: Rest and warm rice sock to face and right ear Treatment: Ibuprofen and Tylenol cold Denies history of allergies to drugs, foods, latex, animals, or environmental factors Denies: use of tobacco products or vaping products Pertinent ROS Denies: fever/ chills/night sweats Denies: watery, itchy or painful eyes Denies: sore throat, difficulty swallowing, shortness of breath, or sneezing. Patient does report: Body aches, nasal congestion, clear to yellow nasal drainage, anosmia, headache, facial pain, right ear pain and pressure, as well as an intermittent non-productive cough especially at night Pertinent PE HEENT: Maxillary sinuses are tender upon palpation Clear fluid is noted in the right ear, however, there is no erythema or edema Nasal turbinates’ are erythematous with edema and clear to yellow Drainage noted bilaterally Post nasal pharynx is pink and moist with the presence of Drainage Halitosis noted Cardiopulmonary: S1S2 heard with no additional heart sounds Bilateral breath sounds clear and equal in all lobes