HEENT Soap Note

REVIEW OF SYSTEMS

General: The patient, a 14-year old white boy, has presented to the clinic in the company of his mother. The mother gives the subjective information on the boy’s behalf, which includes where they live (as a family of four, including the boy’s father and younger brother), the mother’s nature of business, and the boy’s details – he is a student at a nearby school. The present ailment started three days ago, and has been getting worse every day. The boy has had a running nose, a dry cough, and has suffered a loss of appetite. 

Skin: okay. 

HEENT: The boy complains of a mild headache. The eyes are teary. His ears have no discharge. There is excess nasal drainage, with the fluid being very light and thin. There are complaints of a sore throat. 

Respiratory: The patient has some difficulty breathing, though not pronounced. 

Neck/throat: the neck is okay. 

Breasts: okay 

GI: okay

Female G/U: N/A

PHYSICAL EXAMINATION 

General: Patient has a running nose, is fatigued, and has a sore throat. He has a slight cough, with no discharge. His eyes are teary, but not itchy. 

Skin: okay

HEENT: Physical examination records an excess discharge from the nose. The ears have no discharge, but the throat is moderately inflamed. 

Respiratory: Excess mucus seen in the lungs, but expected to clear as the patient receives medication. 

Neck/throat: okay 

Breasts: okay

GI: Working normally. 

Female G/U: N/A

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ASSESSMENT: Common Cold

Differential Dx: allergic reaction to dust particles 

PLAN/Treatment:

Pharmacological intervention will involve a daily intake of Chlor-trimeton, an antihistamine medication. The patient should take this once a day. This will help eliminate the running nose. The patient should take plenty of water at home, as well as adequate rest. A saline gurgle is recommended to minimize the discomfort caused by the sore throat. The gurgle will reduce the inflammation, and the pain caused during coughing .The patient will receive a cough syrup to help eliminate the cough.