Discussion: Drug generic names
Discussion: Drug generic names
· Make sure all pseudo names.
· Patient primarily needs to be the source of the information. For very young children then a parent or guardian but not only the clinical files.
· Subjective information is when you the clinician asks the patient questions to get a clinical history regarding the review of systems. You don’t have to write the exact questions you asked we just need to know
the clinical history.
Eyes: No history of blurred Vision, double Vision, eye pain or eye discharge. No history of foreign body. Never worked grinding metal. Does not wear glasses or contacts.
Ears: No history of hearing problems, ear pain, discharge from ear.
Neurological: No history of headache, dizziness, numbness, seizure, tremor, loss of balance.
· Objective information is the information you as the examining clinician finds during your head to toe detailed assessment.
Eyes: Conjunctiva red bilaterally with white sclera. Pupils are equal, round, and reactive to light and accommodation size 4>2mm. No oedema of eyelids, no blepharitis noted bilaterally. Extra Occular ROM normal bilaterally. Visual acuity 6/9+1 (R) eye & 6/9+3 (L) eye. Near vision unremarkable in both eyes. Red reflex present bilaterally. No strabismus, no nystagmus. Fundoscopic exam normal, vessels intact, optic disc with clear margins, no hemorrhages or exudates, no arteriolar narrowing. Discussion: Drug generic names
Ears: Acuity good to whispered voice. Tympanic membranes intact with good cone of light. Mild wax noted. Weber = midline. Rinne test = AC > BC.
Neuro: Patient alert and orientated to person, time and place. GCS 15/15. CN I-XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar: Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→S) intact. Fluid Gait with normal base. Romberg: maintains balance with eyes closed. No pronator drift noted. Sensory: Pain & light touch = normal. Position sense, stereognosia, Graphesthesia and Extinction = Normal. Vibration intact. Reflexes: 2+ and symmetric with plantar reflexes down going.
· You need to use equipment such as tuning forks, ophthalmoscopes, otoscopes etc… if the department doesn’t have it maybe buy your own.
· Drug generic names
· Drug dosage correct.
· For female patients menstrual cycle is important to document.
· Abbreviations – first use name then abbreviate, recognized abbreviations.
· Length of SOAP notes some 1 page others 11pages
· Diagnostic tests need justification sometimes the risk out-weights the benefit as well as been a cost to the health service and the patient.
· Results of test – no need saying bloods/xray etc… and not saying what the results were.
· Please use same font throughout the SOAP note.
· Please check that sure if the patient is male then he. Sometimes the notes can have both he and she even though the patient is male. Same applies for a female patient.
· Please check information is correct read over before submitting because one SOAP note said that the patient had a caesarean section at 5 years old but I presumed the patient had it five years ago.
· Differential Diagnosis should be a long list of every condition associated with the system involved, please critically think your differential diagnosis and justify your diagnosis.
· Plan of care needs to be the actual plan for your patient not only what the text books say!
· References should be at the end and should be used to support your diagnosis.
· Please check spellings prior to submission here are a few examples of what was in the SOAP 1 & SOAP 2,
Denies – In notes were both Denise and Denis – these are two names.