The Course of the Patient’s illness

/in /by

 

SOAP NOTE

Name: Date: Time: Age: Sex: SUBJECTIVE CC:

The reason was given by the patient for seeking medical care “in quotes”

HPI:

Describe the course of the patient’s illness, including when it began, the character of symptoms, location

where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other

related diseases, past illnesses, surgeries, or past diagnostic testing related to present illness.

Medications: (list with reason formed )

PMH

Allergies:

 

Medication Intolerances:

 

Chronic Illnesses/Major traumas

 

Hospitalizations/Surgeries

 

“Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart

disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

Does your mother, father, or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:

lung disease, heart disease, cancer, TB, DM, or kidney disease.

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

 

 

ETOH, tobacco, marijuana. Safety status

ROS General

Weight change, fatigue, fever, chills, night sweats,

energy level

 

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

 

Skin

Delayed healing, rashes, bruising, bleeding, or skin

discolorations, any changes in lesions or moles

 

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia

hx, TB

Eyes

Corrective lenses, blurring, visual changes of any

kind

 

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis,

hemorrhoids, eating disorders, ulcers, black tarry

stools

Ears

Ear pain, hearing loss, ringing in ears, discharge

 

Genitourinary/Gynecological

Urgency, frequency burning, change in color of

urine.

Contraception, sexual activity, STDS

Fe: last pap, breast, mammo, menstrual

complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

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