Patient Initials:

Gender:

AGE:

Ethnicity:

Date:

SOAP Template
CC:
HPI:

NEWS:

PMH INJURIES
GYN G_______P______ A______ Practices SBE Weeks Gestation LMP

PSH HOSP
Last PAP Last Mammogram

Allergies: Immunizations current: Medications: SH: Tobacco: P/Years

Vocation: Living Situation:

Last Tetanus
ETOH: Exercise: Occupation:

Last Flu
Drugs: FH Mother: Father: Other:

Last Pneumonia

ROS (Check = normal)

Constitutiona Any Fatigue, weakness, malaise, fever, chills, sweats, night sweats, sudden wt loss or gain LBS: l: HEENT: Any HA, dizziness, vertigo, changes in vision, eye pain, double vision, eye redness, eye swelling, or eye discharge Any earaches, ear infections, changes in hearing, nasal discharge, sinus pain, nasal obstructions, or nosebleeds Any seasonal allergies, hay fever, change in smell, mouth pain, sore throat, dental pain, difficulty swallowing, changes in voice or taste Any neck pain with movement, lumps or swelling Pulmonary: Any Hx Lung Dx, SOB, wheezing, cough, pain while trying to breath, or sputum Cardiac: Any chest pain, palpitations, cyanosis, nocturia, dyspnea w/exertion, nocturnal SOB, SOB that increases with lying down, or edema GI Any changes in appetite, episodes of heartburn, abdominal pain, nausea, vomiting, diarrhea, constipation, or bloody or black stools. GU Any frequency, urgency, dysuria, increased or decreased urine pattern, hesitancy, incontinence, or flank, groin, pelvic or low back pain MSK Any pain, stiffness, or swelling of joints. Muscle pain, cramps or weakness. Problems with gait, coordination, or range of motion. Neurological Any weakness, numbness, fainting, tremors, or seizures. Difficulty with memory, confusion, changes in mood, or anxiety Endocrine Any excess urine, thirst, or wt loss. Any heat/cold intolerance, increased sweating, tremors, or nervousness Hematologic Any easy bruising, bleeding, or lymph node tenderness Psychiatric Any anxiety, depression, difficult coping, excess crying, or mental illness Allergies: Any hay fever, runny nose Skin/Hair: Any changes in skin pigment, rashes, excess dryness or moisture. Changes in hair/nail color or texture.

BP

Pain

Location

wt

ht

BMI

Donald L Bons RN, FNP Student, Gonzaga University _____________________________________________

Patient Initials:

Gender:

AGE:

Ethnicity:

Date:

GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.

HEAD: normocephalic ENT: External auditory canals and tympanic membranes clear, hearing grossly intact. No nasal discharge. Oral cavity and pharynx normal. Teeth and gingiva in good general condition EYES: PERRL, EOMI. Fundi normal, vision is grossly intact NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. ABDOMEN: Soft, flat, non-tender without masses or hepatosplenomegaly. Bowel sounds are active. Femoral pulses normal, no bruits. MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. SKIN: Skin normal color, texture and turgor with no lesions or eruptions. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal. GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inguinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge. RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular. PELVIC: Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness. BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy. ABNORMAL ROS: ABNORMAL PHYSICAL EXAM FINDINGS:

Assessment: Most likely diagnosis: Differentials:

Plan:

Donald L Bons RN, FNP Student, Gonzaga University _____________________________________________