Using the information from your HEENT examination of Tina Jones write a SOAP it should be a review of one other student’s SOAP note, commenting on identifying content that you did not include in your own SOAP note and discussing why inclusion of those areas may be important in reaching an appropriate assessment.<\/p>\n
This is the students own work { we did not talk about has been highlighted}<\/p>\n
Michael Uche posted Jun 9, 2025 8:23 PM<\/p>\n
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Adjust automatic marking as read setting<\/p>\n
Patient initials:<\/strong> T.J. SUBJECTIVE<\/strong><\/p>\n Chief Complaint:<\/strong> My throat is sore and itchy, and my nose won\u2019t stop running.<\/p>\n HPI:<\/strong> T.J. is a 28-year-old African American woman presenting with a one-week history of sore, itchy throat, persistent clear nasal discharge, and itchy eyes. She rates her throat pain as 4\/10 and throat itches as 5\/10, with symptoms worse in the morning. She has used throat lozenges with mild relief, but has not used any medication for nasal or eye symptoms. She denies cough, fever, sinus pressure, or recent illness, and has no known exposures to sick contacts. She denies a personal history of seasonal allergies but notes her sister has \u201chay fever.\u201d Her symptoms are constant and not associated with any particular trigger.<\/p>\n Past Medical History:<\/strong> Asthma diagnosed in childhood. Last hospitalization at age 16. Uses albuterol inhaler 2\u20133 times weekly.<\/p>\n Social History:<\/strong> Non-smoker, denies alcohol and drug use. No occupational or environmental triggers identified. Lives alone and does not exercise.<\/p>\n Family History:<\/strong> Sister with seasonal allergies (Hay fever).<\/p>\n Allergies:<\/strong> Penicillin (rash).<\/p>\n Medications:<\/strong> Albuterol inhaler PRN.<\/p>\n Review of Systems (abbreviated):<\/strong>General: Denies fatigue, fever, chills. OBJECTIVE<\/strong><\/p>\n Vital Signs:<\/strong> BP 142\/82, HR 86, T 98.7\u00b0F, RR 16, SpO2 98% RA<\/p>\n Physical Exam:<\/strong>General: Alert, oriented, no acute distress. Diagnostics:<\/strong> None indicated at this time.<\/p>\n ASSESSMENT<\/strong><\/p>\n Primary Diagnosis:<\/strong> Allergic rhinitis \u2013 Supported by clear nasal discharge, itchy eyes, boggy pale nasal mucosa, absence of fever, and family history of allergic symptoms (Ball et al., 2023). Posterior cobblestoning suggests postnasal drainage.<\/p>\n Differential Diagnoses:<\/strong><\/p>\n 1. Viral upper respiratory infection \u2013 less likely given the duration, lack of fever, and absence of sick contacts.<\/p>\n 2. Non-allergic rhinitis \u2013 possible, but history and exam more consistent with allergic etiology.<\/p>\n PLAN<\/strong><\/p>\n References<\/strong><\/p>\n scholarly articles no older than 5 years.<\/p>\n \u00b7 Must use Articles that have DOI numbers \u00b7 You must double-check the APA format to ensure it is done correctly and listed alphabetically.<\/p>\n \u00b7 Do not use bullet points<\/p>\n \u00b7 3 references<\/p>\n the document included was from my soap note<\/p>\n","protected":false},"excerpt":{"rendered":" Using the information from your HEENT examination of Tina Jones write a SOAP it should be a review of one other student’s SOAP note, commenting on identifying content that you did not include in your own SOAP note and discussing why inclusion of those areas may be important in reaching an appropriate assessment. This is […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","meta":[],"disciplines":[13],"paper_types":[],"tagged":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/43920"}],"collection":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions"}],"about":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/types\/questions"}],"author":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/comments?post=43920"}],"version-history":[{"count":0,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/43920\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/media?parent=43920"}],"wp:term":[{"taxonomy":"disciplines","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/disciplines?post=43920"},{"taxonomy":"paper_types","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/paper_types?post=43920"},{"taxonomy":"tagged","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/tagged?post=43920"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
Age:<\/strong> 28<\/p>\n
Eyes: Itchy eyes, blurry vision with prolonged reading.
ENT: Sore throat, runny nose with clear discharge. Denies sinus pressure or ear pain.
Respiratory: Denies shortness of breath, wheezing, or cough.
GI\/GU: No complaints.
Skin: Denies rashes.
Psych: No anxiety or depression reported.<\/p>\n
HEENT: Normocephalic, atraumatic. Eyes: mild conjunctival injection, right eye vision 20\/40, left 20\/20. Fundoscopic exam shows mild retinopathic changes on the right.Tympanic membranes clear. Nasal mucosa boggy and pale. Posterior pharynx mildly erythematous with cobblestoning. Tonsils 1+, no exudate.
Neck: No lymphadenopathy, thyroid non-enlarged. Acanthosis nigricans noted.
Respiratory: Lungs clear to auscultation bilaterally.<\/p>\n\n
Please ensure that the in-text citation matches the references listed<\/p>\n