Heent soap - Study guides, Class notes & Summaries
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Diagnostic Reasoning Case Study
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Diagnostic Reasoning Case Study 
 
 
Jennifer Hood 
University of Texas Arlington College of Nursing and Health Innovation Nursing 5333 Family Nursing I 
Kashiris Perryman, DNP, APRN, FNP-PC June 12, 2021 
 
 
Soap Note 
S/ Identifying Information: 
 
Martha 
26 yo female 
DOB July 12, 1995	 
 
Family Hx: 
	Mother--DM (Alive) Father—COPD (Alive) 
Brother—No preexisting conditions (Living) 
	Personal/Social Hx: 
Chief Complaint/RFE:	College Graduate 
Currently employed as a schoolteacher Fin...
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Heent (Unlimited Attempts) with SOAP Note Completed Shadow Health
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Heent (Unlimited Attempts) with SOAP Note Completed Shadow Health 
 
Shadow Health HEENT Documentation Notes
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EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+
- Exam (elaborations) • 2 pages • 2022
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EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+ 
SOap Note Blue Print 
Course: NURS5102R50 Student: Emily Young Faculty: Dr. Tracy Collins 
Pt Initials: HH Age: 57 Race: Hispanic Sex: M New Pt: Y Established Pt: 
Info Source: Patient Reliability: Reliable E&M Code(s) I.10 
S CC: Elevated blood pressure 
HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier 
and it was high, my wife convinced me to come in.” Patient describes a...
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AHA wk 3 Review Questions exam with complete solution graded A+
- Exam (elaborations) • 3 pages • 2023
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C (abd soft and nontender is an objective assessment finding) - Of the following, which is NOT 
considered subjective information? 
A. Ear pain for 5 days 
B. No cough noted 
C. Abdomen soft, nontender 
D. "I have a headache" 
A (how many times) - You are gathering information from a patient for the HPI portion of your SOAP 
note. Of the following information, what else might you include in this section? 
a. How many times the patient has experienced the symptom in the past 
b. The medication ...
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Erin Bradley i-Human Case Study CC: Nausea and Vomiting SOAP Note #3 2023 All the Sections Latest Updates question and Answers.
- Exam (elaborations) • 9 pages • 2023
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Erin Bradley i-Human Case Study CC: Nausea and 
Vomiting SOAP Note #3 2023 All the Sections Latest 
Updates question and Answers. 
SOAP Note #3 
3/23/2021 
Chief complaint: Nausea and vomiting, feeling shaky and hot along with a flutter in chest 
1. Identifying data: 
Name: Erin Bradley 
Age: 21 
Sex: Female 
Source: Patient who is a reliable historian. 
2. HPI: 
Ms. Bradley is a 21 years old college student who appears to be moderately distress 
with complaints of worsening weakness, nausea...
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Clinical Log Detailed Report
- Other • 134 pages • 2022
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Chamberlain 	Re- Family Nurse Practitionerport Date/Time: 6/11/2019 1:56:56 PM 
Report Filters: 
Report Calendar Year: 2019 
Selected User(s): Scott, Dorothy 
Selected Course(s): NR511: Differential Diagnosis and Primary Care Practicum(10871) Selected Session(s): May 2019 
Selected Status: Accepted 
 
 
 
Course Name:	NR511: Differential Diagnosis and	Clinical Site:	Affordable Quality Care	Patient Initials:	EC 
Primary Care Practicum (10871)	Log Date:	05/07/2019	Age Range:	1-4 years 
Course Sec...
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NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) NURS 5220 HEENT SOAP A.IBAR
- Exam (elaborations) • 8 pages • 2023
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NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) 
NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) 
NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) 
NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) 
NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) 
NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors) 
NURS 5220 HEENT SOAP A.IBARRA(verified by expert tutors)
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NR 511 Week 3 Soap Note.
- Exam (elaborations) • 9 pages • 2023
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NR 511 Week 3 Soap Note.Patient Information: 
K, 65 year old, female, insured 
Subjective Data 
CC: "cough" 
HPI: Presents with cough that started a week ago is not getting better, wakes her, cough now causing her chest to hurt, points to area on right side that she reports it hurts every time she takes a deep breath. States is more tired, easily winded when walking, decreased energy. Tried some 
cough syrup which did not stop cough for long. 
Current Medications: Daily multivitamin, Evista 60...
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Clinical Log Detailed Report
- Other • 135 pages • 2023
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Clinical Log Detailed Report – 
Chamberlain College Of Nursing. Tx: Referral to opthamology and prescribe Singulair, Proair HFA, Albuteral inhaler 
Education: Triggers to avoid to prevent asthma flair up. ; Signs to look for to seek medical help. ; Use inhaler as prescribed. ; Take singulair in order to help prevent 
asthma flair up. ; place a cool rag behind your neck and laydown to help with headache and take OTC tylenol to help alleviate the pain. 
 ; 
Scott, Dorothy 
Pa...
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NR511 Week 1 Exam
- Exam (elaborations) • 21 pages • 2024
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Define diagnostic reasoning - Reflective thinking because the process involves questioning one's thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. 
Seen as a kind of critical thinking. 
What is subjective data? - What the patient tells you, complains of, etc. 
Chief complaint 
HPI 
ROS 
What is objective data? - What YOU can see, hear, or feel as part of your exam. 
Includes lab data, diagnostic test results. 
Com...
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