Get Answer: Soap Note Exercise Question Guide
This question focuses on applying theory to practical scenarios.
What This Question Is About
This question relates to soap note exercise and requires a structured academic response.
How to Approach This Question
Focus on explaining concepts clearly and supporting them with examples.
Key Explanation
This topic involves soap note exercise. A strong answer should include explanation, application, and examples.
Original Question
SOAP Note Exercise- Writing the ASSESSMENT IDENTIFYING INFORMATION Name: A.B DOB: 02/22/1980 Address: 111 Sunny Drive, Sunny, IL Phone: 222-2222 Sex: F Race: Asian Marital Status: Single Usual Occupation: Firefighter Present Occupation: Firefighter Usual Source of Medical Care: Dr. Smith Source and Reliability of Information: Patient, Reliable Insurance Provider: BCBS of Illinois Date of Visit: 2/22/21 CHIEF COMPLAINT “My right eye has been red for a few days now” HISTORY OF PRESENT ILLNESS This is a 42 year-old Asian female who presents to the office with complaints of right eye redness for three days. Last office visit was 2/22/21 for an annual physical with no significantly physical or lab findings. Reports usual state of health is excellent and denies any significant medical history, only seeking care for regular wellness exams. Patient reports right eye redness for three days with itchiness, green discharge, eye irritation, and frequent tearing. States eye irritation is worse in the morning due to eyelid matting. Describes pain as dull, achy, and “gritty”. States pain started at a 1/10 three days ago and was a 3/10 when she woke up this morning. Reports feelings a foreign body sensation in her eye. She took Ibuprofen 600 mg once 2 days ago with no relief. She has also done a warm compress to the right eye that provides some relief. States pain and eye irritation gets worse the longer she has her right eye open. Reports keeping eye closed helps relieve symptoms. Reports husband had the flu one week ago. Wears glasses and last eye exam 2020 with no changes in prescription. Reports difficulty completing her work on the computer due to eye itching and foreign body sensation. Denies cough, fever, sore throat, and swollen lymph nodes. Denies recent travel. Denies any liquids splashed in the eye or any recent eye trauma. Denies visual disturbances, halo lights, light sensitivity, eye coordination, swelling, glaucoma, cataracts, or recent eye infections. Denies any seasonal or environmental allergies. Pertinent Past Medical/Surgical History Denies any medical conditions, surgical procedures, or injuries Medications Denies use of prescriptions medications, any other OTC medications, vitamins, herbal or home remedies Allergies Denies any drug, including PCN, latex, food, seasonal or environment allergies. Pertinent Social History/Habits Denies caffeine use Alcohol- 6oz glass of red wine once a week Denies current/past use or history of tobacco, including cigarettes, vaping, e-cigarettes, or exposure to secondhand smoke Denies current/past use or history of recreational drugs Pertinent Review of Systems General: Denies fever, chills, malaise, fatigue, night sweats, weight changes HEENT: see HPI; denies changes in condition of skin, moles, nails, hair, and scalp; denies hearing loss, use of hearing aids, ear pain, discharge from ear, tinnitus, or ear infections; denies sinus pain, infections, nose bleeds, frequent URIs, runny nose, or discharge; denies dental problems, bleeding gums, oral lesions, sore throat, difficulty swallowing, voice change or hoarseness; denies stiffness in neck, ROM limitations, or swelling of the neck or lymph nodes PULM: Denies cough, sputum production, shortness of breath, or wheezing; denies history of asthma, pneumonia, bronchitis, emphysema, or TB exposure CV: denies heart problems, hypertension, chest pain, heart murmur, palpitations, exercise intolerance, edema, claudication, or rheumatic heart disease Cholesterol levels have never been checked GI: 1-2 soft formed, brown stool daily; denies diarrhea, constipation, straining of BMs, rectal bleeding, nausea, vomiting, abdominal pain, swelling of glands in groin, food intolerance, or history of PUD, gallbladder disease, or hepatitis GU: denies dysuria, hematuria, frequency of incontinence, nocturia, or vaginal discharge; denies history of UTI/STI Menstrual History: LMP 01/10/21- 28-day menstruation cycle with 5-6 days of light flow and moderate cramping, well controlled with Midol; age of menarche 12; nulliparous; last pap smear 02/22/2021, no abnormal findings Sexual History: heterosexual with men; 1 current partner and 3 lifetime partners; currently sexually active and using condoms for contraception, denies history of STIs MS: denies falls, muscle or joint pain, stiffness, ROM limitations, impaired gait, swelling, or weakness Neuro: denies history of head injury, loss of consciousness, problems with coordination, numbness, tingling, seizures, tremors, headaches, impaired cognitive functioning, memory impairment, irritability, mood swings, depression, and suicidal ideations Hem/Endo: denies anemia, sickle cell disease/trait, bleeding tendency, or history of blood transfusions, thyroid problems, hot or cold intolerance, polyuria, polydipsia, and polyphagia PHYSICAL EXAMINATION GENERAL: A.B. is 5’3″, 130 lbs, appears well, appropriately dressed. T. 97.6; BP 112/62, sitting; P 60, radial regular; R 14, equal and unlabored; O2 100% RA. HEENT: Head is upright, midline, still, Facial features symmetric. Skull and scalp symmetric with bones indistinguishable. Hair is smooth and symmetrically distributed. No temporal bruits auscultated. Vision 20/20 without glasses for near vision in each eye and 20/20 with glasses for far vision in each eye. PERRLA. Smooth, full coordinated movement of eyes. Light reflected symmetrically from both eyes. Inflamed conjunctiva in right eye. Green discharge present in right eye. Crusting present on right eyelid. Auricles in alignment without masses, lesions, or tenderness. Auditory canals with minimal cerumen bilaterally. Tympanic membranes are pearly gray, non-injected, intact, with bony landmarks and light reflex visualized bilaterally. Responds appropriately to questions, able to repeat 100% of whispered letters correctly. Soft palate rises symmetrically, uvula midline. Tonsils are grade 0, pink, and free of exudate. Pharynx smooth, pink, and free of exudate. NECK/LYMPH: Trachea is midline and smooth, moves with swallowing. Thyroid gland is smooth and pliable, rises freely with swallowing. Bilateral symmetry of sternocleidomastoid and trapezius muscles. No gross visible cervical adenopathy. Preauricular, parotid, submandibular, and submental, occipital, postauricular, cervical, and supraclavicular lymph nodes non palpable. CV/PULSE: S1, S2 noted, normal rate, regular rhythm, and no murmurs, rubs, gallop, or extra heart sounds. SKIN: No visible rashes or lesions. Skin is warm and dry. PULM: No increased work of breathing. Lungs clear to auscultation bilaterally with good air movement, no stridor, crackles, rubs, or wheezing. ASSESSMENT
******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."
