Soap Note Reproductive and Urinary Systems, health and

Soap Note Reproductive and Urinary Systems, health and

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 ever 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

Diagnosis

Plan/Therapeutics

Plan:

Further testing
Medication
Education
Non-medication treatments

Evaluation of patient encounter

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