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NR 511 Week 5 Assignment: SNAPPS Presentation Assignment{100%}
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NR 511 Week 5 Assignment: SNAPPS Presentation Assignment
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SNAPPS ORAL PRESENTATION TEMPLATEThis template should only be used to organize your oral presentation, IT SHOULD NOT BE
SUBMITTED.
SUMMARIZE
Using a patient seen in the practicum setting, summarize the H&P into an organized and concise
format.
Your text here 1
CC Nasal Congestion and Drainage with cough
HPI statement
using 36-year-old White male presents to the office complaining of a thick nasal
OLDCARTS drainage and congestion with a cough.
data Onset of symptoms 6 days ago which is starting worsen.
Location of his pain and tenderness is mostly on his forehead, and below
the eyes which he describes as constant, and to the sides of the nares
accompanied with congestion and intermittent cough. He has had an
occasional headache in which he describes as a dull and throbbing and rated
as a 6-8 /10, rhinorrhea in which he describes as mostly thick whiteish
green discharge, with a dry sometimes productive cough at night of thick
white sputum.
His aggravating symptoms are laying down and bending over. His
alleviating factors includes OTC medications. Patient has tried Tylenol
sinus and Mucinex which gives him some relief but it only lasts a couple of
hours..
The patient reports that he has not been able to perform his daily activities
because he just doesn’t feel up to it but denies fatigue.
Additional symptoms include an occasional sore throat and pressure in
nasal area, he states he thinks he might have had a fever but didn’t have a
thermometer
Patient. denies SOB or Chest Pain, denies any eye discomfort or discharge,
Chills, body aches, or ear pain
PMH significant for HTN on Lisinopril, Anxiety and depression on Zoloft,
Seasonal allergies
He is a pack per day smoker
No surgeries noted
Pertinent ROS
General- Pt is afebrile, no chills, weight gain or loss
Head: frontal and maxillary sinuses are tendered to touch
Eyes:Pt denies any itching, blurry vision, or discharge
Ears: Difficulty hearing, pressure, or pain
Nose :Nasal congestion, runny nose,
Lung: No SOB or difficulty breathing
This study source was downloaded by 100000832361371 from CourseHero.com on 01-22-2022 15:22:56 GMT -06:00
https://www.coursehero.com/file/54999390/NR-511-Week-5-SNAPPS-Oral-Presentation-on-Template-1/
, HEART: denies and chest pain
ABD- denies any abdominal symptoms upon
Skin: No rashes or skin lesions
Musculoskeletal- denies any muscle or joint pain, or weakness
Neuro- Pt complains of dull throbbing headache but no dizziness noted
GU/GI- Pt denies any constipation or diarrhea. No painful urination or
difficulty voiding
Pscyh- Pt has no increased anxiety at this moment
Pertinent PE PE: Pt appears tired but is well groomed, alert, and oriented, and responsive
to questions
Head: Frontal and maxillary sinuses are tender to touch
Eyes: pink conjunctiva and white sclera
Ears: TM pearly gray bilaterally, mild cermen noted in external auditory
canal
Nose : nasal mucosa of what is seen there is bilateral thick whitish green
mucus plugs blocking the turbinates, Moderate swelling noted to nasal
bridge and cheeks nasal mucosa of what is seen there is bilateral thick
whitish green mucus plugs blocking the turbinates, moderate swelling noted
to nasal bridge and cheeks
Mouth: no erythema noted on the pharynx but cobblestoning present, uvula
midline, tonsils 2+ bilaterally, lymph nodes non-palpable
Lungs: Anterior and Posterior lung sounds clear bilaterally throughout
Vitals: BP 133/69 HR 76 RR18 sp ox 99% T. 98.9
NARROW
Based on the H&P key findings, identify an appropriate differential.
Acute Sinusitis
Upper Respiratory infection
Allergic rhinitis
This study source was downloaded by 100000832361371 from CourseHero.com on 01-22-2022 15:22:56 GMT -06:00
https://www.coursehero.com/file/54999390/NR-511-Week-5-SNAPPS-Oral-Presentation-on-Template-1/
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