WEEK 2 SOAP NOTE HEENT

SOAP NOTE

Name: Date: Time: 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, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med )

PMH

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart

disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses? 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, marijuana. Safety status

ROS General

Weight change, fatigue, fever, chills, night sweats,

energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin

discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia

hx, TB

Eyes

Corrective lenses, blurring, visual changes of any

kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis,

hemorrhoids, eating disorders, ulcers, black tarry

stools

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of

urine.

Contraception, sexual activity, STDS

Fe: 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, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture

hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness,

paresthesias, black out spells Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night

sweats, swollen glands, increase thirst, increase

hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal

ideation/attempts, 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, 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 grey 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 refill 2 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 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast

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

Bladder is non-distended; 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 non-palpable.

(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is

smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal

Full ROM seen in all 4 extremities as 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 – pending

Urine culture – pending

Wet prep – pending

Special Tests

Diagnosis

Differential Diagnoses

o 1- o 2- o 3-

Diagnosis

o

Plan/Therapeutics

o Plan: ▪ Further testing ▪ Medication ▪ Education ▪ Non-medication treatments

Evaluation of patient encounter