Sample Soap

Student: Greg Cook Date of patient visit: 3/11/2011 3/11/2011 Reason for Patient Visit: Annual physical physical

Identification Identification and problem statement: Patient initials: J. H. Age: 50 Sex: Male Marital Status: Married Race: Caucasian Occupation: Police dispatcher Source of Information: Patient; appears reliable Problem Statement: “I’m here for a physical. It’s been about a year since I’ve seen a doctor. My wife and I are applying for foster foster parent status and are required to have a physical”.

Subjective HPI: 50 y/o white male presents today for annual physical. physical. Patient states requires physical for foster parent status approval. Patient states that he is usual state of “good health”. Reports that he has occasional “problems with hemorrhoids” (occasional notice of bright red streaks on stool and toilet paper after passage of large hard stools). States that his hemorrhoids hemorrhoids are not currently currently causing him any problems. He also reports reports occasional and and self-limiting self-limiting episodes of  diarrhea, which he attributes to stress s tress (currently symptom free). Denies chest/abdominal pain. States usually has one formed formed stool in morning. Denies change in bowel bowel frequency or consistency (except as previously noted). Denies nausea/emesis. Denies dark tarry stools. Denies recent weight weight gain/loss. Eats regular diet with with no recent changes. His only other complaints complaints are for seasonal itchy eyes, sneezing, and runny nose (currently symptom free). Pertinent Medical Denies chronic medical conditions. Immunizations up to date (last TD 2006). 2006). States passed 5mm kidney stone 2007. 2007. Right ankle fracture fracture (non-displaced, football) 1991. 1991. Preventive screenings: colonoscopy colonoscopy (never). Patient does not want colonoscopy because he does not like the, “idea “idea of anesthesia”. anesthesia”. Last eye exam 2010, last dental exam 2009. Current Medications Medications NKDA. Ibuprofen, 600mg 600mg PO prn knee pain.

Surgical History Vasectomy 2007. Family History Father died at 74 years of age from “prostate cancer that traveled to brain”. brain”. Mother living (85 (85 years old) old) has history of  “glaucoma and osteoarthritis”. osteoarthritis”. Has one sibling sibling (brother, 57 years old) with history of “hypertension, otherwise in good health”. Social History  The patient reports reports his health health to be “pretty good”. He never smoked and admits to drinking 1 six-pack of beer every month or so. The patient is married married and has no children. He is is physically physically active outside of work (plays intramural baseball and takes care of his three horses), horses), but does not participate in routine routine aerobic aerobic exercise. exercise. He consciously watches his caloric and fat intake, but is otherwise on a regular diet. diet. He is is sexually active in a monogamous relationship. relationship. He denies the use of recreational recreational drugs. His wife also works works outside of the home and they are both self-supportive on their current combined incomes. He has no current current concerns regarding regarding his activities of daily daily living. Review of Systems General Reports in usual state of “Good” health and weight. Denies fever, chills, recent recent weight gain or loss, weakness, fatigue, pain. States that his last physical exam was in 2010. Skin Denies recent rashes or changes in texture or moles. HEENT Denies headaches. Denies problems problems with vision vision or hearing. hearing. Wears reading glasses, last last eye exam 2010. Denies use of hearing hearing aids. Denies glaucoma or cataracts. Denies frequent nasal congestion/stuffiness, but occasional seasonal teary eyes, runny nose and sneezing (currently asymptomatic). Denies nosebleeds. Denies permanent/removable permanent/removable dental prosthetics. prosthetics. Last dental exam 2010. 2010. Denies swollen glands/limps, neck stiffness. Thorax and Lungs Denies history of lung disease, allergies, or asthms. Denies episodes episodes of unexplained unexplained shortness shortness of breath. breath. Cardiovascular Denies “heart trouble”, high blood pressure, rheumatic fever, heart murmurs, irregular beat, palpitations, or chest pain/discomfort. No prior stress test test or EKG. Peripheral Vascular Denies extremity edema, coldness, leg cramps, skin ulcers. Abdomen Regular diet. No swallowing difficulties. Denies problems

with nausea/vomiting, nausea/vomiting, heartburn, or food intolerances. Regular diet. No recent change change in weight. weight. Denies chronic diarrhea, but has has selflimiting episodes of diarrhea diarrhea which he attributes to stress. Also reports episodic problems with hemorrhoids with blood on toilet paper and streaking of passage of hard stool. s tool. States currently has a couple small hemorrhoids with with no bleeding. Denies history of jaundice, gall bladder, or liver disease.

Genitourinary Denies urinary frequency, hesitancy, incontinence, or burning with urination. History of passing 5mm kidney stone stone 2007. 2007. In a long-term monogamous relationship. Denies sexual issues. Metabolic/Hematologic Denies thyroid problems, heat/cold intolerance, excessive excessive hunger, thirst, or history of diabetes. diabetes. Denies concerning bruising, ease of bleeding. bleeding. No history of blood transfusions. Psychiatric Denies trouble concentrating, nervousness, anxiety, or panic attack. Denies difficulty difficulty falling or staying asleep. Occasional (once/week) getting out of bed earlier than waking time to urinate (associated with drinking fluids at night). Denies mood changes, hearing voices, frequent unhappiness, or desire to harm self or others. Denies nightmares, memory memory loss, or excessive excessive life stresses. No recent deaths in family or close friends. Musculoskeletal Right ankle fracture (football, non-displaced) 1991. Occasional pain both knees, which he attributes to years of playing sports and not to a traumatic traumatic event. Denies other orthopedic orthopedic injury or arthralgia. Neurologic Denies history of stroke, seizures or frequent/incapacitating headache. Denies tremors. Objective General Appearance 50 year-old male who is awake, alert, and cooperative. Clothing is is well kept and appropriate for season. He is is oriented to person, place, and time and answers all questions appropriately. Appears stated age, appears to be healthy, and does not appear to be in any acute distress. Vitals BP Right Right arm arm sitting. 152/92 HR 72 RR 16 Sa02 99% on room air

 Tympanic temp 98.7

Head Normocephalic, short cut hair clean with fine texture. texture. Scalp with no lesions, tenderness. TMJ full ROM without without clicks o pain bilaterally. No frontal or maxillary sinus tenderness. Eyes Symmetrical, sclera white, conjunctiva pink. No drainage. drainage. PERLA 3/2. Fundoscopy (without pharmacologic mydriasis): mydriasis): red reflex present, no hemorrhages, lens opacities, disk cupping, papillidema, optic vessels appreciated 2:3 AV ratio. Visual acuity deferred. Ears External ear, ear, no lesions, masses, drainage, or tenderness. CN I grossly intact. Otoscopic exam: TMs TMs pearly grey with + cone of light, light, no bulging, no erythema, landmarks appreciated bilaterally. Nose No nasal flaring. flaring. Septum midline, midline, turbinates pink and moist. No lesions, polyps, or nasal discharge bilaterally. Throat and Mouth Membranes pink/moist. Uvula is midline, tonsils at pillars, no redness or exudates. Neck   Trachea midline. midline. Thyroid and lymph nodes nodes not palpable. Breasts Inspection: no gynecomastia, nipples symmetrical, everted, no drainage. Palpation: Breasts/axilla Breasts/axilla node palpation deferred. deferred. Heart No JVD at 90 degrees. Carotids not assessed. S1 best at apex. S2 best at base. No extra extra sounds. Thorax and Back No abnormal curvatures. Symmetrical expansion with respiration Lungs Lung fields not palpated/percussed. Anterior and Posterior lung lung fields clear to auscultation. Abdomen Round and non-distended non-distended with no scars, striae. No abdominal tenderness to palpation. Liver and spleen not palpable. palpable. Normoactive tympanic bowel sounds x 4, no abdominal bruits. Extremities (Upper) Nails without cyanosis or clubbing. Muscles well developed. Distal pulses +2. Capillary refill < 3 seconds. Full active active ROM. ROM. (Lower) Nails without cyanosis or clubbing. Muscles well developed. Distal pulses +2. Capillary refill < 3 seconds. Full active ROM. Hair

growth + great toes bilaterally. Negative Homan’s. Homan’s.

Skin Color consistent with race. Warm, dry, intact with good turgor. No peripheral/central peripheral/central cyanosis. No obvious rashes. Multiple small (