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SOAP notes and dictation

Discussion in 'Clinical Rotations' started by shigaT, Jul 21, 2002.

  1. shigaT

    shigaT Member
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    hi all,

    i'm in my first rotation of third year (family medicine) and the doc i work with dictates all pt encounters. now, he's expecting me to do dictations in the SOAP format and my problem is i don't have the medical lingo down - especially for the objective part of the note. does anyone have any ideas where i could get a sample SOAP with all the normal findings (in medical lingo) on PE?

    thanks, shiga
     
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  3. Mindy

    Mindy Senior Member
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    Here is a sample PE (some of the terms are repeated because I wanted my template to be complete. When you do your objective focus only the parts that were covered during the interview. Physical Examination

    Include the basic information about every system involved: Inspection, Palpation, Percussion, Auscultation. Refer to Bates, or keep a pocket guide of phys. diagnosis on you.
    ---------------------------------------------------------------------------------
    VITAL SIGNS temperature, pulse (rate, rhythm, volume, character), respiratory rate, blood pressure (include orthostatics and pulsus paradoxus If applicable), weight Vital Signs: pulse and regularity, BP (orthostatics and bilateral pressures if indicated), temperature, respiratory rate

    GENERAL level of consciousness, apparent stats of health, signs of distress, stature and habitus, posture, dress, grooming and personal hygiene, odors of body or breath (fetor hepaticus, uremia), affect, relationship to persons and things General: general appearance, apparent state of health, nutrition, development, stature, gross deformities, skin coloration, level of distress

    SKIN color, temperature, moisture and turgor, texture, description of lesions, nails (clubbing, splinter hemorrhages) and hair Skin: texture, rashes, lesions (characterize including description, number, location, distribution), pigmentation, nails

    HEENT: Head: shape, hair distribution, lesions; Eyes: visual acuity, visual fields, conjunctivae and sclerae, pupils, fundoscopic exam; Ears: hearing, discharge, auricular pain, appearance of tympanic membranes. Nose: obstruction, mucosa discharge. Mouth: sores, dentition, mucosa, tongue, gums, floor of mouth; appearance of tonsils, pharynx, uvula, palate

    HEAD configuration and symmetry, masses, tenderness

    EYES EOMs, eyebrows, eyelids, conjunctiva, sclera, cornea, anterior chamber, lacrimal apparatus, iris, pupils, red reflex, lens, vitreous and fundus (optic disc, vessels, macula)
    EARS auricles, mastoid area, TMJ, external ear canals, tympanic membrane, auditory acuity

    NOSE external symmetry, patency, septum, turbinates, polyps, smell, and sinuses

    MOUTH lips (cyanosis, lesions), buccal mucosa, teeth, gums, floor of mouth, tongue, hard palate, soft palate, tonsillar fossae, pharynx

    NECK tracheal deviation, venous pressure (including hepatojugular reflux), masses, thyroid, carotid pulses, lymph nodes (in all chains), auscultate for thyroid and carotid bruits. Neck: flexibility, masses, thyroid, tracheal deviation Lymphatics: cervical, submandibular, supraclavicular, axillary, epitrochlear, inguinal, femoral, (characterize size, number, consistency, mobility, tenderness)

    CHEST rate, rhythm and effort of breathing, AP diameter, interspaces (pediatric patients), tactile fremitus, percussion for dullness/resonance and excursion of the diaphragm, auscultation for breath sounds, vocal fremitus, egophony Pulmonary/Chest: Inspection: symmetry, spinal deformities, spine or CVA tenderness, tracheal deviation; Palpation: fremitus, tenderness; Percussion: clarity, symmetry, diaphragmatic excursion; Auscultation: character of breath sounds, adventitious sounds (crackles, rubs, wheezes, egophony, vocal fremitus)

    BREASTS symmetry, consistency, tenderness, masses, nipples, skin retraction, dimpling, discharge Breasts: appearance, asymmetry, tenderness, masses, nipple discharge

    AXILLAE skin abnormalities, lymph nodes

    HEART pulsations, PMI, rate, rhythm, heart sounds, extra sounds, murmur (site of maximal intensity, grade, radiation and change of murmur with maneuvers) Cardiovascular: Neck Veins: level, wave, CVP, changes with respiration. Heart: Inspection. Palpation: PMI, lifts, heaves. Auscultation: rate, rhythm, S1, S2, murmurs (grade, location, radiation, timing (systolic, diastolic) maneuvers), rubs, gallops. Pulses: carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibialis. (Note strength, character, bruits.)

    ABDOMEN inspect skin (including scars), contour, symmetry, masses, visible peristalsis, pulsations, auscultate for bowel sounds, bruits of aorta, renal, iliac or femoral arteries, palpate for masses, tenderness, guarding or rebound, liver span, spleen tip, hernias, percuss for fluid shift Abdomen: Inspection: distended/flat/scaphoid, abnormal movements, dilated veins, striae, scars; Ausculation: bowel sounds, bruits, rubs; Palpation: tenderness, guarding, rebound, ascites, masses, liver, spleen, aortic aneurism; Percussion: distention, organ size, shifting dullness

    BACK curvature, tenderness, and range of motion

    FEMALE GENITALIA ** performed only when indicated - External: development, sores, scars. external genitalia, vagina, cervix, uterus, tubes, ovaries, rectovaginal septum Females: appearance of vulva, perineum, vaginal walls, cervix, and vaginal discharge; cervical motion tenderness, size and position of uterus and adnexa, abnormal masses.

    MALE GENITALIA ** performed only when indicated - External: development, sores, scars. lesions, discharge, scrotal contents, hernias Male: hydrocele, variocele, testicular masses, tenderness, urethral discharge, hernias, circumcision.

    ANUS AND RECTUM ** performed only when indicated - lesions, tone, prostate, masses, occult blood Rectal: external lesions, hemorrhoids, sphincter tone, fissures, prostate (size, texture, nodules, tenderness), masses, stool (color, consistency), fecal occult blood test.

    MUSCULOSKELETAL skin (color changes, scars, temperature, edema, tenderness), joint position (is the joint position abnormal), joint outline (thickened synovium, fluid, localized tenderness), joint motion (active, passive, abnormal) Extremities: Inspection: deformity, nodules, clubbing, edema, symmetry, skin color, temperature, texture; joint ROM, effusions, erythema, tenderness, synovial thickening

    NEUROLOGICAL mental status, abnormal movements, speech (content, fluency, articulation), memory, cranial nerves, cerebellar function, sensory (light touch, pinprick, vibration) and motor function (strength, tone, reflexes) Neurological: Mental status: level of consciousness, orientation, mood/affect, speech (naming, repetition, fluidity), recall (registration, short term, long term), attention, commands, abstractions, judgement, insight, delusions, hallucinations. Cranial nerves: pupils (symmetry, reactivity, size), corneal reflex, extra-ocular movements, facial sensation, movement and symmetry, air and bone sound conduction, gag reflex, shoulder shrug, sternocleidomastoid strength, tongue movement. Motor: atrophy, tone, fasciculations, tremor, strength (0-5 scale), pronator drift. Sensory: light touch, pain, temperature, vibration, proprioception. Reflexes: DTR's (symmetry, 0-4 scale), Babinski. Cerebellar function: rapid alternating movements, finger to nose, heal to shin. Gait: steadiness, symmetry. Romberg.

    good luck!
    Mindy
     

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