NSG 6020 Soap Assignment – Soap Outline

NSG 6020 Soap Assignment – Soap Outline

NSG 6020 Soap Assignment – Soap Outline

SUBJECTIVE

Chief Complaint (CC)
Brief statement of the nature and duration of the symptoms that caused the Pt to seek medical attention stated in the Pt’s own words.

History of Present Illness (HPI)
Detailed chronological description of the development of the Pt’s illness from the appearance of the first symptom to the present time.

Past Medical History (Med/Surg HX)
A summary of all illnesses, such as acute infectious diseases, accidents, operations, allergies, drug sensitivities.  In women the number of pregnancies and abortions would be noted.

Social (Personal) History (SH)
Statements of marital status, habits, social history, occupation & environment.

Family History (FH)
A record of diseases among relatives in which heredity or contact may play a role, such as allergies, infectious diseases, mental, metabolic, endocrine, cardiovascular or renal diseases, or neoplasm. Health of immediate relatives, ages at death & causes of death should be recorded.

Review of Systems (ROS)
The purpose of this systemic inventory is to reveal subjective symptoms which the Pt either forgot to describe or which at the time seemed relatively unimportant.  Generally an analysis of the subjective findings, as related by the Pt, will give a clue to the diagnosis & will indicate the nature & extent of the physical examination required. Include the following data but in continuous paragraph form: Constitutional: Skin; HEENT; Respiratory; Cardiovascular; etc.

Constitutional:  nutrition, fever, night sweats, falling hair, weight gain or loss & any occupation or habit that might have a bearing on the development of the disease.

Skin:  a record of eruptions, cyanosis, jaundice, or other skin conditions.

Head:  headache (duration, severity, character, location).

Eyes:  eyestrain, pain diplopia, photophobia, lacrimation, glasses, inflammation, blurring, scotomata.

Ears:  deafness, discharge, tinnitus, dizziness, pain.

Nose:  head colds, epistaxis, discharge, obstruction, post-nasal drip, sinus pain.

Throat:  soreness, redness, hoarseness, difficulty in swallowing.

Respiratory:  chest pain, hemoptysis, expectoration, dyspnea, cough, night sweats, date of last chest film.

Cardiovascular:  chest pain, asthma, palpitation, tachycardia, faintness, vertigo, edema.

Gastrointestinal:  appetite, thirst, nausea, vomiting, hematemesis, melena, colic, jaundice, constipation, diarrhea, food idiosyncrasies.

Genitourinary:  dysuria, frequency, nocturia, incontinence, pyuria, hematuria.

Menstrual:  periods (frequency, type, duration), dysmenorrhea, menorrhagia, symptoms of menopause, contraceptive pills or devices, date of last menstrual period.

Neuromuscular:  motor weakness, joint pain, paresthesia, varicosities, deformities.

Psychological status:¬†¬†personality type, emotional state, headaches, convulsions, paralysis, ‚Äúnervous breakdown,‚ÄĚ environmental stress, memory loss, insomnia, nightmares, sociopathic behavior.

Soap Outline Con.

NSG 6020 Soap Assignment – Soap Outline

OBJECTIVE

Vital signs:  weight, height, temperature, pulse, respiration, blood pressure.

Physical Examination Findings:

General: posture, nutritional & emotional state, apparent age, severity/acuteness of illness.

Skin: color, texture, pigmentation, ecchymosis, petechiae, hair distribution, nails, myxedema, sweating, lesions, icterus, etc.

Head ‚Äď Eyes:

Skull and scalp: configuration, scars.

Lids: edema, ptosis, lid lag.

Sclera:  Jaundice, hemorrhage.

Conjunctiva:  pallor, injection, petechiae.

Cornea:  scars, ulceration.

Pupils:  size, shape, equality, reaction to light and accommodation.

Vision: acuity, visual fields.

Opthalmoscopic:  optic discs, vessels, exudate, hemorrhage.

Ears:  tympanic membranes, canals, hearing, discharge, etc.

Nose: airways, mucosa, septum, sinus tenderness, discharge, bleeding, smell, etc.

Mouth: breath, lips, teeth, gums, tongue, salivary ducts, etc.

Throat: tonsils, pharynx, palate, uvula, postnasal drip, etc.

Neck:  stiffness, masses, thyroid, vessels, trachea, lymph nodes, salivary glands.

Lymphatics:  location of palpable nodes; size, consistency, mobility and tenderness.

Thorax:  shape, symmetry, respiration, etc.

Breasts:  masses, discharge, nipples, tenderness, etc.

Lungs:  fremitus, breath sounds, adventitious sounds, friction, spoken voice, whisper

Heart:  apical impulse, thrill, pulsation, rhythm, sounds, murmurs, gallop, friction rub.

Hematologic / Blood vessels: pulses, quality, vessel walls.

Abdomen: contour, peristalsis, scars, rigidity, tenderness, spasm, masses, fluid, liver, kidneys, spleen, hernia.

Genitourinary: scars, lesions, discharge, penis scrotum, epididymis, varicocele, hydrocele

Rectal: fissure, fistula, hemorrhoids, sphincter tone, masses, prostate, seminal vesicles, feces.

Vaginal: external genitals, Skene’s & Bartholin’s glands, vagina, cervix, uterus, adnexa

Musculoskeletal:  deformities, swelling, redness, tenderness, limitation of motion.

Extremities:  color, edema, tremor, clubbing, ulcers, varicosities.

Neurological: cranial nerves, coordination, reflexes, biceps, triceps, patellar, Achilles, abdominal, cremasteric, Babinski, Romberg, gait, sensory, vibratory.

ASSESSMENT (Prioritized Impressionable Diagnoses)

A tentative or provisional diagnosis made by the practitioner examining the Pt; it’s made based on subjective findings as related by the Pt & the objective findings as found by the practitioner.  Prior to making the diagnosis, the symptoms & physical signs of several diseases from which the Pt may be suffering are compared.  This process is called Differential Diagnosis (DDx).  The present illness determines whether or not DDx’s are indicated.  By process of elimination of differential diagnoses, the provisional diagnosis may be determined.

NSG 6020 Soap Assignment – Soap Outline

PLAN

The plan includes recommendations for treatment, including testing, medications, other therapies, Pt education & follow-up appointments.

 

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