Focused Episodic Note sample
Focused Episodic Note sample
Chief complaint: headache and pressure
History of presenting illness: CT is a 49years old Caucasian female presenting with a headache at the temporal region bilaterally. The pain is of acute onset three days ago. Initially, the pain was on a scale of 9 out of ten and gradually reduced to 5 out of 10. It is pounding nature and radiates to the frontal head and eye region. Aggravating factors are exertion or moving the head and relieved by resting. It is associated with nausea, vomiting, photophobia, and phonophobia. The patient complains of facial pressure with a stuffy nose, nasal blockage, malaise, and sneezing. However, she denies fever and shortness of breath. Focused Episodic Note sample
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Past medical history: she has hypertension and manages it by restricting dietary sodium. She denies hospital admission, surgical procedures, and blood transfusion.
Allergies: she denies food and drug allergy
Immunization: her immunization schedule is up to date. Her last tetanus vaccine was three months ago, and she is yet to receive the pneumococcal vaccine in three months.
Social history: CT is married and lives with her husband. She works as a call center manager with a bachelor’s degree in communication. She enjoys reading novels, hiking, and traveling. She enjoys taking deep-fried food and coffee. She denies smoking and taking alcohol.
Family history: she is the firstborn in a family of two. Her younger brother 45years old has no record of chronic illness. Her father and mother are hypertensive and on treatment. Her grandparents died due to old age. She denies a family history of cancer, asthma, and mental illnesses.
Review of systems: the patient denies coughing, chest pain, shortness of breath, abdominal pain, reflux, dysuria, hematuria, polyuria, numbness, weight loss, and night sweats.
General examination: The patient is alert and oriented to time, place, and person. She has no pallor, jaundice, cyanosis, edema, dehydration, or lymphadenopathy.
Vitals: blood pressure at 141/87mmHg, pulse 88beats per minute, temperature 37.1, and pulse ox at 98%.
HEENT: the patient has facial erythema and periorbital edema. The are purulent nasal secretions, mucosa erythema, edema, and purulent discharge from the middle meatus. There is a nasal septal deviation with turbinate hypertrophy. The sense of smell and taste are intact. The head is a-traumatic without scars. The throat and palate are moist and erythematous.
Respiratory systems: the chest wall has symmetrical expansion when breathing in. There is a resonant percussion note and vesicular breath sounds. There is no tachypnea, rhonchi, stridor, and crackles.
Cardiovascular system: the heart is palpable at the 5th ICS. There are n parasternal heaves and thrills. The heart sounds S1 S2 is present without murmurs. The peripheral pulses are present with a regular rhythm and rate. Focused Episodic Note sample
Allergic rhinitis J30.9
Covid 19 U07.2
Sinusitis is the inflammation of the paranasal sinuses with or without concurrent rhinitis. Its symptoms are headache, photophobia, phonophobia, facial fullness or pressure, post nasal discharge, blocked nose, fever, fatigue, coughing, sneezing, and running nose (Allevi, et al, 2021). Causes of sinusitis can be infections from bacteria, fungi, viruses, and nasal polyps. Nasal congestion is a result of the accumulation of mucus and inflammation of the sinuses. This causes manifestation by bacteria or fungi, hence causing purulent nasal discharge. This is the primary diagnosis because the patient presents with similar symptoms; headache, photophobia, nasal blockage, facial tenderness, and erythema.
Allergic rhinitis is the inflammation of the nasal membranes characterized by nasal congestion, itchiness, rhinorrhea, itching eyes, nose, and the palate, post nasal drip, headache, red eyes, swelling, malaise, and drowsiness (Zhang, et al, 2021). It is a result of exposure to an allergen like dust, fur, cold, and pollen. These symptoms disappear after the withdrawal of allergen. This is not the actual diagnosis because the patient has no known allergies.
Covid 19 is a respiratory tract infection presenting with fever, coughing, shortness of breath, cough, fatigue, headache, muscle pain, headache, running nose, diarrhea, nausea, vomiting, sore throat, congestion, and loss of taste (Struyf, et al, 2021). It is more prevalent in patients with asthma, hypertension, cystic fibrosis, immune deficiencies, and liver disease. This is not the actual diagnosis because the patient denies fever, coughing, and shortness of breath.
Diagnostic investigations are nasal cytology to rule out allergic rhinitis, eosinophilia, and aspirin sensitivity. A serological test for HIV is important in patients with recurrent sinusitis. A complete sinus CT scan with frontal and coronal planes helps in excluding tumors and allergic fungal sinusitis. A chest radiograph and throat swab for microscopy help rule out covid 19. Rhinoscopy evaluates the nasal mucosa for polyps and purulent drainage.
- Pseudoephedrine 60mg PO three times daily to relieve pain and ease congestion.
- Oxymetazoline nasal spray once daily for three days to relieve congestion
- Amoxicillin 500mg PO three times daily to prevent rhinosinusitis. Focused Episodic Note sample
Adequate hydration, smoke cessation, humidification, and warm compresses.
The assessment session was informative. The patient was cooperative during the interview and physical examination. Sinusitis is the inflammation of the sinuses commonly caused by upper respiratory tract infections. The patient experiences recurring severe headaches. The patient should sleep head propped up, take plenty of fluids to keep the mucus thin and inhale steam to avoid recurring. Focused Episodic Note sample