Christine Dominguez

SOAP Note # 4

SOAP NOTE FORMAT

ID
11/07/2015, DM, 22 year old single male. Unknown religious preference. Patient is presently
covered under his parents insurance.
CC
Yearly physical
HPI
Patient arrives with no complaints of illness.
PMH
Patient has a history of tonsillectomy, due to frequent sore throats. He has no allergy symptoms.
He is in generally good health, and reports no serious illnesses, and has only been hospitalized
for his tonsillectomy. He has received all age specific immunizations, takes no medications, and
has no known drug allergies. Psychiatric history unknown.
PERSONAL HISTORY
Patient is a Hispanic male, single, presently a student in a local college, living with his parents.
Unknown safety or abuse issues.
HEALTH HABITS
Unknown tobacco, alcohol, illicit drugs. Patient states he has no dietary issues, does not
participate in a regular exercise program.
HEALTH MAINTENANCE
Patient states he sees the dentist every six months, sees an optometrist regularly. He states he
cleans ears regularly but states he doesnt insert q-tips inside his ears. Patient does not perform
regular testicular exams.
FAMILY HISTORY
Patient states he has no family history of sudden death from cardiovascular disease. Unknown
additional family history.
REVIEW OF SYSTEMS
GENERAL
States no current medical problems, feels generally well, reports no diaphoresis, chills or
malaise.
DIET
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Christine Dominguez

SOAP Note # 4

Patient states he has no dietary issues, states his appetite is good.

SKIN, HAIR, NAILS
Patient states he is experiencing no rashes, pruritis, or lesions,. He states he has no suspicious
moles that have him concerned. He does admit to facial acnes, and states he uses benzyl peroxide
which is effective.
HEAD AND NECK
Patient denies headaches, dizziness or episodes of loss of consciousness.
EYES
Denies visual disturbances but wears contacts and glasses. Sees optometrist on a regular basis.
States no color blindness,
EARS
Patient states no drainage from ears, no reported hearing loss
NOSE
No congestion, epistaxis, or nasal discharge. No problem with sinuses or nasal allergies
THROAT AND MOUTH
States he has no swallowing issues, states good oral hygiene without ulcers or teeth problems.
GASTROINTESTINAL
States no tenderness or abdominal pain, denies constipation or diarrhea,
LYMPH
States no lymph node tenderness, no problems swallowing
ENDOCRINE
Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased hat, glove, or
shoe size
MALE
Patient states he has not experienced changes in testicles, problems with erection, or pain.
CHEST AND LUNGS
Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, and exposure to TB
No problems with dyspnea on exertion or shortness of breath. He states no asthma symptoms or
prior history of asthma, denies cough.
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Christine Dominguez

SOAP Note # 4

CARDIOVASCULAR
Patient denies chest pain with exercise. No palpitations or decreased exercise tolerance reported.
HEMATOLOGY
Patient states he has no unexplained bruising, no history of anemia.
GENITOURINARY
Patient denies trouble with urination, frequency, burning or nocturia.
MUSCULOSKELETAL
Patient denies any joint pain or swelling.
NEUROLOGIC
Patient states he does not dizziness with exercise
MENTAL STATUS
Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts
Physical Examination
VS
TPR, BP 116/79, 120/82, Ht; 70 inches, Wt; 161 lbs, BMI; 23
BP in left and right arm are comparable.
GENERAL APPEARANCE
Patient is a 22 year old Hispanic male standing erect, with alignment of extremities. No evidence
of kyphosis or lordosis.
MENTAL STATUS
Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality
Alert and oriented to time, place and person. Patient is awake and alert with a clear and concise
speech pattern noted.
SKIN
Even, uniform, tan in color. No rashes, no itchy areas, rashes, lesions, suspicious moles. Rash on
face. Nails of feet and hands clean and dry, no abnormalities noted
HEAD
Hair clean and dry, no deformities, no dandruff noted.

Christine Dominguez

SOAP Note # 4

NECK
Neck is symmetric, trachea midline, carotid arteries without bruit. Patient is able to flex, extend,
rotate and turn his head in all directions. No jugular venous distention noted.
EYES
Pupils equal and reactive to light. Pupils are round, measuring 2mm, brisk, light reflex and
accommodation intact.
EARS
Pt able to hear words in bilateral ears with whisper test. Ears are without lesions or discharge,
Otoscopic exam notes no bulging or perforation in tympanic membrane, translucent.
NOSE
Sinuses palpated without tenderness or swelling.
MOUTH AND THROAT
Lips and gums pink, without lesions or exudate. Tonsils absent
CHEST/LUNGS
Lungs are clear bilaterally, chest size with 1:2 AP ratio. Chest is resonant to percussion
bilaterally.
BREASTS
No swelling or masses noted in breast tissue
HEART
Rate is regular and even, no murmurs, no S3, S4 noted.
BLOOD VESSELS
Good capillary refill of < 3 seconds, no clubbing or cyanosis noted. Radial pulses 3+, pedal
pulses 2+
ABDOMEN
Active bowel sounds all four quadrants, abdomen non tender with palpation, no masses
appreciated. Percussion dull at RUQ at liver border, able to palpate liver edge.
MALE GENITALIA
Not assessed
RECTUM/PROSTATE
Not assessed
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Christine Dominguez

SOAP Note # 4

MUSCULOSKELETAL
Smooth even ROM of shoulders, wrists, hands. Patient is able to move his head, stretch his neck
in all directions. Able to bend at waist forward, side to side and back. Able to lift his knees from
standing position, bend down, touch toes. Back is symmetric, no scoliosis noted. Strong hand
grasps and strength with resistance, strong legs with resistance
NEUROLOGIC
Positive patellar reflex on right side present, able to touch finger to Eyelid nose bilaterally.
CRANIAL NERVES
I: Not assessed
II: Not assessed
III, IV, VI: Not assessed
V: Not assessed
VII: Patient is able to raise eyebrows, smile symmetrically.
VIII: Not assessed
IX, X: Not assessed
XI: Pt able to shrug his shoulders, rotate and flex his neck
XII: Not assessed
Diagnosis:
Health physical without specific abnormalities
DIFFERENTIALS
Not applicable
PLAN:
Patient encouraged to perform self-testicular exam. Information given to patient on how to
perform self testicular exam, as patient states he does not know how it is performed. Discussed
the importance of monthly self exams, and to seek medical care for any masses or pain noted.