Write a sample SOAP note documenting T.Q.'s visit to the clinic
What will be an ideal response?
Answers to this question will vary widely.
S: 20-year-old male with complaining of "runny nose." Denies any cough, headache, sore throat,
fatigue, or muscle aches. Only current medication is 0.66 mL/kg gamma globulin (GamaSTAN) IM
every 3 weeks.
O: Well developed, well nourished, alert, and cooperative. Appears to be in no acute distress. Nares
do not appear swollen or red, some clear mucous drainage present. External auditory canals and
tympanic membranes clear. Oral cavity and pharynx normal; no inflammation, swelling, exudate,
or lesions. No adenopathy or sinus tenderness; lung sounds are clear to auscultation. Vital signs
110/60, 76, 18, 98.4 ° F (36.9 ° C).
A: No current signs of infection present.
P: Administer gamma globulin as directed.
Instruct on signs and symptoms that would signal development of a respiratory infection and when
to notify the physician and return for follow-up care
Instruct on general self-care measures to prevent infection.
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The healthcare provider prescribes an iron supplement for a client with chronic kidney disease. Which health problem is this medication intended to prevent?
a. Edema b. Uremia c. Anemia d. Oliguria
Individuals taking angiotensin-converting enzyme (ACE) inhibitors that decrease blood pressure by increasing sodium and water excretion should be monitored for which of the following possibly related to foods or seasonings consumed?
1. Hyperkalemia 2. Hypercalcemia 3. Hyperphosphatemia 4. Hypermagnesemia
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A) Apples B) Asparagus C) Carrots D) Bananas