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Essay Available:
Pages:
1 page/≈275 words
Sources:
2 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Coursework
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 5.83
Topic:

SOAP Note for Meniere’s Disease

Coursework Instructions:

For the disease ****Meniere's disease*** provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.
Subjective
CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective
Vital signs/BMI
Physical exam findings
Diagnostic results (include actual "results" or “findings” that you would expect for a certain scenario)
Assessment/Plan
Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem
Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up

Coursework Sample Content Preview:

T2 DQ2: Meniere’s Disease SOAP
Student Name
Institutional Affiliation
Course Code and Name
Professor
Assignment Due Date
T2 DQ2: Meniere’s Disease SOAP
Subjective
Chief Complaint by the patient was, “I hear a ringing or buzzing sound in the right ear and dizziness which has lasted the past 24 hours.” The patient is a 40-year-old male who reports feeling dizziness, reduced hearing, and nausea. The symptoms have been occurring at intervals of 2-3 hours. Past medical history indicates that the patient has an intellectual disability and neonatal seizure. Also, at the age of 20 years, the patient had congenital heart disease and underwent cardiac surgery. Also, the patient denies using tobacco or alcohol and is married with two children.
Objective
The patient does not feel l any pain in the ear and has no discharge. No fever, headache, visual loss, or blurred vision was observed. The patient has a temperature of 99.8, a BP of 140/86, and a height of 5’11” and weighs 250 pounds. The heart rate is regular, with no murmurs. The Pure Tone Audiogram (PTA) showed the presence of sensorineural hearing loss in the right ear. Results from the CT imaging of the right ear temporal bone showed soft tissue densities in the mid-ear. The results and symptoms point to a primary diagnosis ...
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