Please Write Assessments Explained for Students (Easy Guide)

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Original Question

Please write out and Assessments and Plan for this patient that includes the medical care, consultations with others that may help provide the patients care. This care should show that you have considered the research, evidence-based theory and Practice Knowledge?:CC: Patient presents for follow up exam.HPI: Patient presents with nasal congestion, sneezing, and a cough for 2 days. Right sided sinus pressure. Patient says it she woke up yesterday with these symptoms. Nasal discharge is yellow. Notes she does have a history of sinus infections. Pt saw a specialist that said her right sinus is smaller than the left. This does feel like a sinus infection. Has been taking Airborne and Mucinex with some relief. Denies chills and fevers. ROS:Const: Denies chills and fever.ENMT: Denies mouth or throat symptoms.CV: Denies chest pain.Resp: Denies symptoms other than stated above.GI: Denies diarrhea, nausea and vomiting.GU: Urinary: denies dysuria and incontinence.Musculo: Denies joint pain.Skin: Denies rash.Neuro: Denies numbness/tingling.Psych: Denies depression. Current Meds: Biotin 5000 mcg, Centrum Silver Ultra Womens, Fish Oil 1200 mg, Calcium 1000 + D 1000-20 MG-mcg, Vitamin B Complex, Montelukast Sodium 10 mg, Potassium Chloride Crys ER 20 Meq, Triamcinolone Acetonide 0.1 %, Klor-Con M20 20 meq, Amlodipine Besylate 5 mg, Venlafaxine HCL ER 37.5 mg, Arimidex 1 mg, Omeprazole 20 mg, Losartan Potassium 100 mg, Vitamin D3 Maximum Strength 125 mcg (5000 Ut), Aspirin 81 mg, Venlafax

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