SOAP
For this assessment, we used a SOAP sheet.
However, since this was not a real patient, we did not fill out the assessment and plan sections.
Patient
"S" subjective
My patient was Brenda, she came in for a complaint about knee pain. She has no medical conditions and is on no medications. However, she is allergic to dust.
What I did/learned
I learned how to do a basic head-to-toe assessment, which included the study of an eye and what the motion of the eye means, the normal sounds of GI, symmetry, and how to assess a patient.
Assessment
"O" objective
- Vitals:
- B/P: 118/76 - Gender: Female
- T: 98.5 - Age: 14
- P: 68 - Race: White
-R: 16
Gastrointestinal:
- GI normal
- Normal bowel sounds
_No abdomen irregularities
- Normal bowel movement
- No urination issues
Head and Arms:
- Range of motion regular
- No drift
- Sensations on arms normal
- Passed cap refill test
Lungs and Thorax:
- Lungs good
- No reported respiratory issues
- Spinal curvature good
Neck and Shoulder:
- Neck rotation good
- Shoulder resistance good
- Negative JVD
Mouth and Throat
-Jaw good
-Teeth and gum healthy
- Tongue, uvula, and tonsils good
Head/Face
- Tan
- Symmetric
- Health hair, no lice
- No bumps
Eyes:
-Pupils healthy
- Peripheral vision good
- Vision good
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