Soap Note: Meniere disease
SUBJECTIVE:Routine Follow up/Chronic ConditionChief Complain:Symptoms analysis/HPI:PMH:Immunization:Surgical History:Family History:Social Hx:CONSTITUTIONAL:Neurologic:HEENT: Head:Eyes:. Ear:Nose:. Throat:Respiratory:Cardiovascular:describe aboveGastrointestinal:Genitourinary:MusculoskeletalSkin: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:CardiovascularGastrointestinal: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, 5
