Soap Note: Meniere disease case study

SUBJECTIVE:

Routine Follow up/Chronic Condition

Chief Complain:

Symptoms analysis/HPI:

PMH:

Immunization:

Surgical History:

Family History:

Social Hx:

CONSTITUTIONAL:

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Neurologic:

HEENT: Head:

Eyes:

. Ear:

Nose:

. Throat:

Respiratory:

Cardiovascular:

describe above

Gastrointestinal:

Genitourinary:

Musculoskeletal

Skin:

Objective data:

CONSTITUTIONAL: Vital Signs T: °F (Oral), HR: bpm, regular, RR: , BP: , SpO2: % on room air, Weight: , Height in BMI . Report pain 0/10.

General appearance:

NEUROLOGIC:

HEENT: Head:

. Eyes: PERRLA, sclera white, no discharge noted.

Ears:

Nose/Sinus:

Mouth:

Throat:

Neck:

Respiratory:

Cardiovascular

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary:

Assessment:

Differential diagnosis: is based in secondary causes of diabetes

• These basic laboratory tests are:

Pharmacologic treatment:

Non-Pharmacologic treatment:

Education Non-Pharmacologic treatment:

•

Office procedures:

Follow-ups/referrals:

in one week for evaluation follows up.

References: Less 5 years ago. APA format

Soap Note: Meniere disease case study