How to Answer Please This Information Questions (Complete Guide)

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What This Question Is About

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Key Explanation

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Original Question

Can you please put this information into a SOAP note. Subjective Data section only. Case #1 A 36-year-old female with a medical history of Multiple Sclerosis (MS) complains of constantly feeling tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been on Interferon. As a wife and mother of 2 with a full-time job, she states that by the end of the day she has no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a few months back, but it has gotten progressively worse. She also mentions that she has missed several days at work over the last 4 weeks because after getting showered and dressed, she had no energy left to go to work. Reports occasional glass of wine on the weekends, denies tobacco use or illicit drug use. She has tried some CBD oil to help with energy without relief. Reports sleeping more than eight hours a night while needing several naps throughout the day. She reports uncomfortable buzzing sensation traveling from neck down to spine with what sounds to be a Lhermitte’s sign. She denies loss of bowel or bladder. She denies fever, chills, weight loss or weight gain. She reports some nasal congestion but contributes that to allergies which she takes cetirizine 10 mg PO daily for. Reports she up to date on her pap smear, does monthly self-breast exam, denies concerns on exam. Saw her dentist and eye doctor within the last year and no issues or concerns there. Reports her mother who is alive has diabetes and hypertension. Her father and siblings are also alive without any health issues. She does have an aunt on her mother’s side who had MS as well who is currently wheelchair bound. She is alert, oriented to person, place, time and situation. Does not appear in acute distress, well-developed, slightly obese in the abdominal section. Skin is dry, warm, and intact. Normocephalic, neck supple, no thyromegaly. PERRLA about 4mm pupil size. Conjunctivae rim pale. Optic fundi examined revealed uniform red to pink color, disk is pale pink, vessels emanate from optic cup, fovea was slightly darker. Retinal vessels are free from hemorrhages or exudates. Face symmetrical. No lymphadenopathy. Oral mucosa pink and moist. Heart rate bradycardic at 56 beats per minute but regular without pauses or extra beats. Lungs diminished bilaterally but otherwise clear. Abdomen soft, non-distended, bowel sounds normoactive in all four quadrants. No suprapubic or CVA tenderness. Able to differentiate between light and deep tough, no dysmetria or ataxia, normal alternating hand movements, gait steady. Muscle tone inspected and palpated, free from fasciculation, tenderness or atrophy. Strength 5/5 in all extremities.

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