Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage

Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there.

He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps.

When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear.

His tonsils are not enlarged but his throat is mildly erythematous

NB

-Please make up the information needed to do your Focused/Episodic Soap note.

-To say N/A is not acceptable.

-For ROS and PE, you do not have to Review all the systems, only the ones that are related to the CC. Always review and examine the Resp and CV system no matter the complaint.

**You will need to put in (MAKE UP) the missing information in the note (some of the information you will have to MAKE UP ie meds, hx, parts of the ROS and PE). I’m looking to make sure you know what information to include.

In the Assessment/Plan, you will document your differential diagnoses as per the assignment.

-YOU WILL MAKE UP INFORMATION IN ORDER TO COMPLETE THE SUBJECTIVE AND OBJECTIVE INFORMTION.

– Use Template Below.