Question

patient is 9 years old and female presents with her mother complaining of a dry cough that “wakes up everyone in the house” each night for the last 2 weeks. Denies prior hx of the same.

What could be HEENT for soap note? (Objective data)

Answer 1

1. First of all write the patient's reason for visit. In this case it will be cough.
2. Than we will write subjective data. Subjective data will include history given by the patient or the attendant. It also includes patients personal and past history.
3. In Objective data-

• Note patients vital signs.
• Check whether the patient is well developed, well nourished or in any acute distress.
• Than check patient skin for any dryness or scaling.
• Check the oropharynx.
• Asess nose for any mucosal swelling, ulceration, tenderness.
• HEENT - check the pupils size, shape, reaction to light and accommodation. Assess extraoccular movement. Listen to the heart sounds whether normal or abnormal. Check extremities for edema, cyanosis, deformities.