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H&P > SOAP > Flashcards

SOAP Flashcards

1
Q

Subjective(Told You)

Name, age, gender, race
Date/Time
CHPPFSMARPLS

A 
CC
HPI
PMH
PSH
FHx
SHx
Meds
Allergies
ROS
Physical Exam (PE)
Labs/Tests
Assessment
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2
Q

Objective (Found on Exam) 18 systems

A 
VS
Skin
Head
Eyes
Ears 
Nose/sinuses
Mouth/throat
Neck
Respiratory
Cardiac
Abdomen
GU
Rectal
MSK (musculoskeletal)
Lymphatic
Neuro
Psych
Extremities
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3
Q

Assessment

A

DDx

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4
Q

Plan

A

Labs, imaging, tests, meds, therapies, referrals, consults, pt education, f/u

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5
Q

PMH

A

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

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6
Q

PSH

A

Date of operations/type, indications for, outcome

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7
Q

FHx

A

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

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8
Q

SHx

A

Alcohol, tobacco, drugs, birthplace, beliefs, education, employment, recreation, marital/relationship status, sexual preference, diet, exercise, travel, hobbies

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9
Q

Medications

A

Name, dose, route, frequency, duration, compliance

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10
Q

Allergies

A

Name of drug and reaction—rash, SOB, swelling, nausea

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11
Q

ROS: General

A

Weight changes, fever, weakness, fatigue, night sweats, chills, body aches, sleep

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12
Q

ROS: Skin/Derm

A

Rash, sores, lumps, itching, color changes, hair, nails

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13
Q

ROS: Head

A

Trauma, HA, N/V, dizziness

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14
Q

ROS: Eyes

A

Glasses, contacts, pain, redness, tearing, vision loss, discharge, double/blurred vision, glaucoma

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15
Q

ROS: Ears

A

Hearing loss/aid, tinnitus, vertigo, earache, discharge

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16
Q

ROS: Mouth/throat

A

Bleeding gums, dentures, cavities, hoarseness, sore throat, dry mouth, painful swallowing

17
Q

ROS: Nose/sinuses

A

Stuffiness, rhinorrhea, sneezing, itching, epistaxis, allergies (perennial, seasonal)

18
Q

ROS: Neck

A

Lumps/masses, goiter, pain, stiffness, swollen

19
Q

ROS: Breast

A

Lumps/masses, skin changes, pain, discharge

20
Q

ROS: Respiratory

A

Cough, SOB, wheezing, sputum (color/quantity), hemoptysis, bronchitis, dyspnea, pleurisy

21
Q

ROS: Cardiac

A

CP, palpitations, murmurs, rheumatic fever, DOE (dyspnea on exertion), orthopnea, paroxysmal nocturnal dyspnea, edema

22
Q

ROS: GI

A

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

23
Q

ROS: Urinary

A

Frequency, polyuria, nocturia, hesitancy, urgency, dysuria, hematuria, incontinence, stones, reduced caliber

24
Q

ROS: Genital

A

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

25
Q

ROS: Vascular

A

Claudication, edema, varicose veins, past clots

26
Q

ROS: Musculoskeletal (MS)

A

Muscle or joint pain, stiffness, arthritis, gout, weakness, swelling, redness, instability

27
Q

ROS: Neurological

A

LOC, numbness, tingling, paralysis, paresthesias, fainting, blackouts, burning, tremors

28
Q

ROS: Hematological

A

Anemia, easy bruising/bleeding, petechiae, purport, ecchymosis, transfusions

29
Q

ROS: Endocrine

A

Heat/cold intolerance, sweating/thirst/hunger

30
Q

ROS: Psychiatric

A

Nervousness, mood, anxiety, depression

31
Q

ROS: Lymphatic

A

Swelling, tenderness, streaking

H&P (11 decks)

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