SOAP NOTE
Title: Date: Time:
Age: Intercourse:
SUBJECTIVE
CC:
Cause given by the affected person for looking for medical care “in quotes”
HPI:
Describe the course of the affected person’s sickness, together with when it started, character of signs, location
the place the signs started, aggravating or assuaging elements; pertinent positives and negatives, different
associated ailments, previous diseases, surgical procedures or previous diagnostic testing associated to current sickness.
Drugs: (record with motive for med )
PMH
Allergy symptoms:
Medicine Intolerances:
Power Sicknesses/Main traumas
Hospitalizations/Surgical procedures
“Have you ever each been instructed that you’ve got: Diabetes, HTN, peptic ulcer illness, bronchial asthma, lung illness, coronary heart
illness, most cancers, TB, thyroid issues or kidney illness or psychiatric prognosis.”
Household Historical past
Does your mom, father or siblings have any medical or psychiatric diseases? Anybody recognized with:
lung illness, coronary heart illness, htn, most cancers, TB, DM, or kidney illness.
Social Historical past
Training degree, occupational historical past, present dwelling state of affairs/accomplice/marital standing, substance use/abuse,
ETOH, tobacco, marijuana. Security standing
ROS
Normal
Weight change, fatigue, fever, chills, night time sweats,
vitality degree
Cardiovascular
Chest ache, palpitations, PND, orthopnea, edema
Pores and skin
Delayed therapeutic, rashes, bruising, bleeding or pores and skin
discolorations, any adjustments in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, TB
Eyes
Corrective lenses, blurring, visible adjustments of any
sort
Gastrointestinal
Belly ache, N/V/D, constipation, hepatitis,
hemorrhoids, consuming issues, ulcers, black tarry
stools
Ears
Ear ache, listening to loss, ringing in ears, discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in shade of
urine.
Contraception, sexual exercise, STDS
Fe: final pap, breast, mammo, menstrual
complaints, vaginal discharge, being pregnant hx
Male: prostate, PSA, urinary complaints
Nostril/Mouth/Throat
Sinus issues, dysphagia, nostril bleeds or
discharge, dental illness, hoarseness, throat ache
Musculoskeletal
Again ache, joint swelling, stiffness or ache, fracture
hx, osteoporosis
Breast
SBE, lumps, bumps or adjustments
Neurological
Syncope, seizures, transient paralysis, weak point,
paresthesias, black out spells
Heme/Lymph/Endo
HIV standing, bruising, blood transfusion hx, night time
sweats, swollen glands, enhance thirst, enhance
starvation, chilly or warmth intolerance
Psychiatric
Despair, nervousness, sleeping difficulties, suicidal
ideation/makes an attempt, earlier dx
OBJECTIVE
Weight BMI Temp BP
Peak Pulse Resp
Normal Look
Wholesome showing grownup feminine in no acute misery. Alert and oriented; solutions questions appropriately.
Barely somber have an effect on at first, then brighter later.
Pores and skin
Pores and skin is brown, heat, dry, clear and intact. No rashes or lesions famous.
HEENT
Head is normocephalic, atraumatic and with out lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with optimistic
gentle reflex; landmarks simply visualized. Nostril: Nasal mucosa pink; regular turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and with out exudate. Tooth are in good restore.
Cardiovascular
S1, S2 with common charge and rhythm. No further sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses Three+ all through. No edema.
Respiratory
Symmetric chest wall. Respirations common and straightforward; lungs clear to auscultation bilaterally.
Gastrointestinal
Stomach overweight; BS lively in all four quadrants. Stomach mushy, non-tender. No hepatosplenomegaly.
Breast
Breast is free from lots or tenderness, no discharge, no dimpling, wrinkling or discoloration of the pores and skin.
Genitourinary
Bladder is non-distended; no CVA tenderness. Exterior genitalia reveals coarse pubic hair in regular
distribution; pores and skin shade is in step with normal pigmentation. No vulvar lesions famous. Nicely estrogenized.
A small speculum was inserted; vaginal partitions are pink and properly rugated; no lesions famous. Cervix is pink
and nulliparous. Scant clear to cloudy drainage current. On bimanual examination, cervix is agency. No CMT.
Uterus is antevert and positioned behind a barely distended bladder; no fullness, lots, or tenderness.
No adnexal lots or tenderness. Ovaries are non-palpable.
(Male: each testes palpable, no lots or lesions, no hernia, no uretheral discharge. )
(Rectal as applicable: no proof of hemorrhoids, fissures, bleeding or lots—Males: prostrate is
clean, non-tender and free from nodules, is of regular dimension, sphincter tone is agency).
Musculoskeletal
Full ROM seen in all four extremities as affected person moved concerning the examination room.
Neurological
Speech clear. Good tone. Posture erect. Stability secure; gait regular.
Psychiatric
Alert and oriented. Wearing clear slacks, shirt and coat. Maintains eye contact. Speech is mushy, although
clear and of regular charge and cadence; solutions questions appropriately.
Lab Checks
Urinalysis – pending
Urine tradition – pending
Moist prep – pending
Particular Checks
Analysis
Differential Diagnoses
o 1-
o 2-
o Three-
Analysis
o
Plan/Therapeutics
o Plan:
▪ Additional testing
▪ Medicine
▪ Training
▪ Non-medication remedies
Analysis of affected person encounter

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