HEENT, Integumentary, and Abdominal Assessment
Using a friend, family member, or colleague, perform a HEENT, integumentary, and abdominal exam. Document the physical examination findings in the SOAP note format.
You should document the expected normal exam findings for the system. The complete subjective and objective sections should be included. If there is no chief complaint, you should devise a complaint to complete the HPI and OLDCART portion of the note. It is not necessary to complete the assessment and plan section of the SOAP note for this discussion.
Discussion posts are supported by evidence from appropriate sources published within the last 5 years. In-text citations and full references are provided.
SOAP Note Format
Patient Information:
Initials, Age, Sex, Race, Insurance
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient's own words - for instance "headache", NOT "bad headache for 3 days".
HPI: include all the information regarding the CC using the OLDCART format. If the CC was "Unintentional weight loss", the OLDCART for the HPI might look like the following example:
Onset: 2 months ago
Location: Generalized
Duration: Steady weight loss, 3-5 pounds per week
Characteristics: Associated with feeling tired, poor appetite, and occasional nausea without vomiting
Aggravating Factors: Food smells increase the frequency of nausea
Relieving Factors: Small, bland meals are better tolerated
Treatment: None reported
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately.
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
SocHx: include occupation and major hobbies, family status, tobacco & alcohol use, any other pertinent data. Always add some health promo question here - such as whether they use seat belts all the time or whether they have working smoke detectors in the house.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relativesshould be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: Constitutional:Head: EENT: etc. You may list these in paragraph format or bullet format. Always document the systems in order from head to toe.You may focus the ROS to match the chief complaint unless you are doing a complete health history.
Example of Complete ROS:
CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: include the same body systems as in the ROS.Include the assessment data for thesystem(s) identified in the discussion instructions. Always document in head to toe format i.e. Constitutional: Head: EENT: etc.
Diagnostic results: when available (from today and past recent tests results if pertinent)
A.
Differential Diagnoses (list a minimum of 3differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. Include the ICD9 or ICD10 codes in parentheses next to the diagnosis. Include pertinent positive and negative findings to support your diagnoses from the history and physical exam.
P.No intervention is self-evident. Provide a rationale and evidence based in-text citation for each intervention
Diagnostics: list tests you will order this visit
Rx:list treatments and medications you will order and "continue previous meds" if pertinent. State dosages, length of treatment and reason for choosing a specific treatment or drug.
Education: think about covering yourself legally; also indicate when written instructions are given.
Referral/Consults: (if any)
Follow up:indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.
References
You are required to include at least one evidence based peer-reviewed journal article which relates to this case. Be sure to use correct APA 6th edition formatting.