SOAP Flashcards
Subjective(Told You)
Name, age, gender, race
Date/Time
CHPPFSMARPLS
CC HPI PMH PSH FHx SHx Meds Allergies ROS Physical Exam (PE) Labs/Tests Assessment
Objective (Found on Exam) 18 systems
VS Skin Head Eyes Ears Nose/sinuses Mouth/throat Neck Respiratory Cardiac Abdomen GU Rectal MSK (musculoskeletal) Lymphatic Neuro Psych Extremities
Assessment
DDx
Plan
Labs, imaging, tests, meds, therapies, referrals, consults, pt education, f/u
PMH
Current Ilnesses: DM, HTN, HIV, COPD
Childhood Ilnesses: chicken pox, measles, mumps, rheumatic fever, rubella, whooping cough
Accidents/Injuries/Transfusions: MVA, hospitalizations
Immunizations: TDaP, MMR, Polio, Hep A/B, HPV
Developmental Hx: milestones, grade level
Consider: Birth Hx, OB/GYN (LMP, Gravida/Parity), TPAL (Term pregnancies, preterm, abortion, living children), Phys/sexual abuse
PSH
Date of operations/type, indications for, outcome
FHx
Age/health/death of family—parents, siblings, children, grandparents
Red Flags: DM, MI, HTN, CAD, Stroke, CKD(chronic kidney disease), TB, cancer, bleeding disorders, anemia, asthma, allergies, alcoholism, drug addiction, mental illness, hyperlinked is
SHx
Alcohol, tobacco, drugs, birthplace, beliefs, education, employment, recreation, marital/relationship status, sexual preference, diet, exercise, travel, hobbies
Medications
Name, dose, route, frequency, duration, compliance
Allergies
Name of drug and reaction—rash, SOB, swelling, nausea
ROS: General
Weight changes, fever, weakness, fatigue, night sweats, chills, body aches, sleep
ROS: Skin/Derm
Rash, sores, lumps, itching, color changes, hair, nails
ROS: Head
Trauma, HA, N/V, dizziness
ROS: Eyes
Glasses, contacts, pain, redness, tearing, vision loss, discharge, double/blurred vision, glaucoma
ROS: Ears
Hearing loss/aid, tinnitus, vertigo, earache, discharge
ROS: Mouth/throat
Bleeding gums, dentures, cavities, hoarseness, sore throat, dry mouth, painful swallowing
ROS: Nose/sinuses
Stuffiness, rhinorrhea, sneezing, itching, epistaxis, allergies (perennial, seasonal)
ROS: Neck
Lumps/masses, goiter, pain, stiffness, swollen
ROS: Breast
Lumps/masses, skin changes, pain, discharge
ROS: Respiratory
Cough, SOB, wheezing, sputum (color/quantity), hemoptysis, bronchitis, dyspnea, pleurisy
ROS: Cardiac
CP, palpitations, murmurs, rheumatic fever, DOE (dyspnea on exertion), orthopnea, paroxysmal nocturnal dyspnea, edema
ROS: GI
Dysphasia, appetite, nausea, vomiting, regurgitation, indigestion, BM freq/color/size, changes in bowel habits, diarrhea, constipation, bleeding (hemorrhoids, Elena, hemetemesis, hematochezia), abdominal pain, jaundice, liver/gallbladder trouble, and last colonscopy
ROS: Urinary
Frequency, polyuria, nocturia, hesitancy, urgency, dysuria, hematuria, incontinence, stones, reduced caliber
ROS: Genital
Sex preference, interest, function, concerns
Male: hernias, penile discharge or sores, testicular pain/masses, birth control method, Hx of STD
Female: Hernias, menarche age, period regularity/frequency/duration, amount, dysmenorrhea, itching, discharge, sores, lumps, STD, menopause, hot flashes
ROS: Vascular
Claudication, edema, varicose veins, past clots
ROS: Musculoskeletal (MS)
Muscle or joint pain, stiffness, arthritis, gout, weakness, swelling, redness, instability
ROS: Neurological
LOC, numbness, tingling, paralysis, paresthesias, fainting, blackouts, burning, tremors
ROS: Hematological
Anemia, easy bruising/bleeding, petechiae, purport, ecchymosis, transfusions
ROS: Endocrine
Heat/cold intolerance, sweating/thirst/hunger
ROS: Psychiatric
Nervousness, mood, anxiety, depression
ROS: Lymphatic
Swelling, tenderness, streaking
