HEENT

/in /by

Head, Eyes, Ears, Nose , Throat 

• A full SOAP- HEENT • I recorded a video for Head, eyes, Ears, Nose, Throat.  All normal findings. 

-The teacher wants a SOAP of the HEENT Assessment.

  I have included some pertinent info that can help you. You can make up what ever. The only abnormalities are listed below otherwise is a healthy person. •

 *Instructions: The student will decide on the Chief Complaint (CC) which must be appropriate for the associated body system. • 

The student will complete all SOAP components • The Subjective section includes the following:ID TS , 25 yoa, Sep 20 1999, male, Caucasian, visit the clinic alone. Historian), CC,  no complaint, HPI: No pass medical history. •

 Helthful info • (No headaches, no glasses, no vision problems, no head trauma, no nodules, no stroke, neck symetric, no thyroid probles, no  goither, cephalic,hear soft, full hair, no skin lessions, • All cranial nerves intact, ROM intac, EOM intact, visual acuity 20/20, visual fields 180° , no nystamus, no bulging, no strabismus… • (using OLDCARTS for problem-focused history) • PMH, Family History:Non pertinent. • PMH previous septum surgery repair 2023 due to car accident,Sinusitis, Septum perforation, seasonal allergies, • Social History (as pertinent), married, works mechanic, sexually active. • ROS (problem-focused based on body system).Denies any respiratory problems, denies cardiovascular problems.  

• The Objective section includes: expected vital signs and the physical examination documentation with detailed focus on the week’s body system (as well as general, and basic assessment of CV and Pulmonary). • The Assessment section must contain 3 differential diagnoses with rationale and in-text citations to credit the evidence-based sources used to defend the diagnosis choices. One of these three diagnoses must be the final or working diagnosis. • The Plan section is based on the working/ final diagnosis. • This must include the five aspects of a plan which are diagnostics, • treatments, education, referral (if applicable), and follow-up. • The student should use in-text citations to credit their sources of information for each aspect of the plan. • The student must use a minimum of two references which should be recent (within last 5, but up to 10 years if clinical practice guideline) and should be peer-reviewed. • Use APA title page, citations, and reference format.