William Fredericks
42 ylo
6'0" (183 cm)
215.0 Ib (97.7 kg)
Reason for encounter
Worsening headache and facial pain, fever
Submitted on
... [Show More] 01/11/2022 13:49:34
Case authored by: Marcia Stout, DNP, APN, FNP-C, CWON
Reason for Encounter
Start with open-ended patient-centric questions.
® Asked X Not asked
Information Obtained Graded Approach Question Response Clinic Notes
I'm here because | feel really sick
and am not getting better. | have
this headache which started
about 2 weeks ago. | was just
[ ] CC Sx How can | help you today? getting over a cold at that time.
Over the last 2 weeks my
headache got worse and more of
my head hurts. It now hurts to
move my eyes.
| can tell you that my face really
hurts now. Is that the same thing?
No one's ever told me | had sinus
problems.
X Assoc Sx | Do you have sinus pain?
Yes, maybe 3? or 5? days ago
my runny nose, which had
resolved, has restarted and
changed from clear to creamy.
Then over the last day or two |
started having low grade fever--
around 99.5 to 100 F. | also have
this strange tooth pain/sensitivity
and ear pain. | feel like | am
falling apart. It's one thing after
another. What a wreck | am!
Do you have any other symptoms [ ] Assoc Sx # or concerns we should discuss?
X Assoc Sx | Do you have a sore throat? Yup. It started with my coughing.
OLD-CARTS for the HPI
® Asked X Not asked
Information
Graded Approach Question Response Obtained
Clinic Notes
| feel it started with my post-nasal
[ ] Onset When did your cough start? drip... Stuff going down the back
of my throat.
When did the pain in your face It started after my headache,
L Onset start? maybe 7-10 days ago.
The headache is above my eyes,
like in my forehead. But now |
have this facial pain, too...
X Location Where more precisely is the pain
in your head?
My left ear is fine, but today |
started having these short stabs
of pain in my right ear.
X iocaitioni Where more precisely is your ear
pain?
It's below my eyes here (points to
region surrounding eyes
bilaterally) and it also feels like |
have a tooth problem on the right.
That pain comes and goes, but
the tooth looks fine. | haven't
Where more precisely is your X Location i i [Show Less]