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Nsg 6430 week 2 soap note 2024 with complete solution; south university
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1Week 2 SOAP Note Assignment
SU_NSG6420_W2_A3_Alimole_A.doc.
South University
NSG 6420
December 13, 2020
, 2
Week 2 SOAP Note Assignment
SOAP Note
Name: B.C Date: December13, 2020 Time: 2:30 pm
Age: 45 Sex: M
SUBJECTIVE
CC: Nasal congestion and pain on the left side of the face for the past three days.
HPI: The patient reported experiencing pain on the left side of the nose and nose
congestion for the past three days. He also c/o itchy throat and cough. He also reported
that the pain gets worse when he bends forwards and worsening of cough on lying down
or doing physical activity. He describes the pain as a throbbing. The patient reports that
the pain is in the left side of his nose that radiates to his left jaw. He additional reported
generalized sporadic dull headaches unrelated to any precipitating events. He rated the
severity of pain on a scale as 4/10. The patient stated that the pain is mainly in the
morning when he wakes up but constant throughout most the day. He reported having a
low-grade fever and feeling fatigued and reported trouble sleeping due to nasal
congestion and cough. He mentioned taking over the counter (OTC) Tylenol for fever and
pain and experienced much relief. He also reported using cough drops but experienced
minimum relief. He denied feeling nauseous, denied vomiting, shortness of breath, and
rashes on the skin.
Medications: The patient is currently not taking any prescribed medication. He reported
taking OTC Tylenol for pain and fever and cough drops for cough. He denied taking any
herbal medication or nutrition supplements.
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