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MSN_SOAP_Note

MSN_SOAP_Note

Name:  Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC: 

Reason given by the patient for seeking medical care “in quotes”

 

HPI: 

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.

 

Medications: (List with reason for med )

 

Allergies: (List with reaction)

 

Medication Intolerances:

Past Medical History:

 

Chronic Illnesses/Major traumas

 

Hospitalizations/Surgeries

 

“Have you ever been told that you have  diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”

 

Family History

Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?

 

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status

 

ROS Student to ask each of these questions to the patient: “Have you had any…..”
General

Weight change, fatigue, fever, chills, night sweats,  and energy level

 

Cardiovascular

Chest pain, palpitations, PND, orthopnea, and edema

 

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

 

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

 

Eyes

Corrective lenses, blurring, and visual changes of any kind

 

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

 

Ears

Ear pain, hearing loss, ringing in ears, and discharge

 

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDs

   Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints

 

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

 

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis

Breast

SBE, lumps, bumps, or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells

Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx

OBJECTIVE
Weight         BMI Temp BP
Height Pulse Resp
General Appearance

Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later.

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal 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 without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable.

(Male:  Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)

(Rectal as appropriate:  No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm).

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes.

Urine culture collected in office—pending results, sent to lab

Wet prep collected in office—pending results, sent to lab

 

Assessment
· Include at least three differential diagnoses

· Provide rationale for each differential diagnosis

· Final diagnosis

· Pathophysiology of primary and rationale for choosing as final

 

Plan
· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up

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