Introduction to PATIENT HISTORY, SOAP NOTES, & PRESENTING

* Technically, you will not be writing detailed notes in the CHC clinic. Usually there is no time for a full review of systems and a complete write up. Instead, focus on writing a thorough and concise note that is easily read by other healthcare providers. The information noted below is for educational purposes.

Common Abbreviations
CC or C/O = chief complaint DOE = dyspnea on exertion DTR = deep tendon reflexes HA = headache HPI = history of present illness Hx = history N/V = nausea or vomiting PMH = past medical history PRN = as needed PSH = past surgical history R/O = rule out REB = rebound ROS = review of symptoms Rx = treatment URI = upper respiratory infection qAM/qPM = each morning/evening FX = fracture ETOH = alcohol H/O or h/o = history of FH = family history LFT = liver function tests QAC = before meals All = allergies SOB = shortness of breath w/ or c/ = with Q # H = every # hrs RTC = return to clinic SH = social history DDx = differential diagnosis UTI = urinary tract infection QHS = nightly NPO = nothing by mouth H&P = history and physical examination LBP = lower back pain QD = daily Chem 7 = electrolyte tests D/C or DC = discharge CBC = complete blood count HTN = hypertension QID = 4 times daily QOD = every other day TLC = therapeutic lifestyle change BID = twice daily PEx = physical examination UA or u/a = urinalysis

1) History Taking a. Chief Complaint (CC or C/O): one sentence description of whats wrong according to the pt b. History of Present Illness (HPI): Use OLDCARTS i. Onset - timing, circumstances ii. Location where in/on the body? iii. Duration including overall chronology, frequency, and length of episodes iv. Characteristics e.g. constant, intermittent, sharp, dull, crampy, mild severe (Scale of 1-10) v. Aggravating/alleviating factors including activities, diet, menses, stress/psych, weather change, medication effects vi. Radiation does pain/illness spread anywhere? vii. Treatment including those already tried, currently on, and their results; medical or herbal remedies viii. Significance what the patient thinks or fears the problem is, how does it affect the pt? c. Past Medical History (PMH)/Past Surgical History (PSH) i. General health ii. Surgeries, hospitalizations iii. Chronic illnesses iv. Childhood illnesses, immunizations v. Other current medications, allergies vi. Any relevant past lab reports/values d. Family History i. Age/health/death of parents, siblings, spouse, children ii. Ask for hx of symptom of present illness, diabetes, heart disease, hypertension, stroke, cancer, bleeding disorders e. Social History

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i. Tobacco, alcohol, recreational drugs ii. Lifestyle, diet, exercise iii. Employment, marriage, housing iv. Seat belts, fire alarms if you want to be thorough 2) SOAP Note Writing a. S = Subjective - Narrative i. One-liner of identifying information: Name, Age, Gender, CC, vital components of medical history ii. HPI = history of present illness iii. ROS = review of symptoms iv. PMH = past medical history v. PSH = past surgical history vi. FH = family history vii. SH = social history viii. Meds: dosages, frequency, purpose, and side effects ix. All = allergies b. O = Objective i. Vitals ii. Physical Exam Results iii. Lab tests c. A = Assessment/P = Plan i. Summary sentence ii. List each problem, what the underlying issue is, and what treatment or recommendation was given to patient iii. Include any follow-up tests under each issue 3) Oral Case Presentation a. Summarize as much as possible in one-liner: demographics, chief concern and duration, significant findings, both positive and negative b. Expand upon the chief concern (OLD CARTS) c. Review of systems (if applicable) d. Pertinent histories: past medical history (PMH/PSH); family hx, social hx e. Physical exam give vital signs here f. Medications, Allergies, Labs Fictional SOAP Note (Dx: Claudication):
Note to M1s/M2s: Remember that this example should only be used at CHC. It is an INTRODUCTION to SOAP notes and thus, should not be considered as an ideal template for clinical preceptorships or hospital clerkships.

S: Mr. Corazon is a 55 yo Hispanic male with a PMH remarkable for essential HTN, stable angina, and 40 pack-yr smoking hx presenting with left calf pain. 1) Left calf pain: Left calf pain began 1 week ago and occurs after walking 2 blocks (onset/aggravating factor). Cramping pain (characteristic) is localized (location/radiation) to the lower 1/3 of the calf and subsides after resting for 5 minutes (duration/alleviating factors). Patient denies taking any medications for his pain (treatment) and admits that his limited mobility interferes with regular activities, such as grocery shopping and afternoon walks (significance). Patient denies any recent leg trauma, instability, nocturnal leg pain, and numbing/tingling sensations of his lower extremities (Pertinent Negatives R/O acute trauma/neuromuscular pathology/peripheral

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neuropathy). Patient believes that his left leg is cooler than his right leg (Pertinent Positive).
If the patient had another complaint, list it as another bullet point and write the HPI next to it.

FH:

Father: hx of HTN for 30 years, died of a heart attack at 52 yo Mother: hx of Type II DM, died at 70 yo of unknown cause Brother: 58 yo, alive and healthy Living Situation: independent living in apartment Support: home nurse visits for 1 hour 2xs per week Employment: retired construction worker Exercise: used to walk 30 min/day until presentation of lower calf pain Diet: consumes fried foods for breakfast and dinner (i.e. chicken, bacon, hamburgers), eats 1 fruit/day Habits: Tobacco: 40 pack-yr smoking hx EtOH: drinks 3-5 beers/week alone Illicit Drugs: denies use

SH:

O: Vitals: HR: 70 bpm, right wrist BP: 135/88, RA, seated RR: 16 bpm Wt: 150 lbs Ht: 54 BMI: 25.7 PEx: General Appearance: Patient is pleasant, alert, cooperative, and seated in no acute distress. Neck: Carotid pulses palpable, bilaterally. No carotid bruits heard. Cardiac: RRR, nl S1, S2. No r/m/g. No pedal edema noted. Decreased tibialis posterior pulse on left side. Pulmonary: Lungs are CTAB. No wheezing/coughing. No use of accessory muscles observed. Abdominal: Soft, NT, distended, NABS. No shifting dullness. No pulsatile masses palpated. No renal, aortic, and iliac bruits auscultated. Musculoskeletal: Joints: No redness, swelling, or stiffness noted of knee or ankle joint. Neurologic: Reflexes: Patellar and ankle reflexes 2+, bilaterally. Babinski reflex absent, bilaterally. Sensory: Propioception and dull/sharp discrimination intact, bilaterally. Strength: 5/5 for hip flexion, knee extension, knee flexion, ankle dorsiflexion, ankle plantar flexion, and great toe extension, bilaterally Gait: within normal limits Extremities: LE: left calf/foot a bit cooler than right calf/foot Labs: Lipids: TG: 275 mg/dL TC: 215 mg/dL LDL: 132 mg/dL HDL: 35 mg/dL VLDL: 48 mg/dL Fasting Glucose: 115 mg/dL A/P: Mr. Corazon is a 55 yo Hispanic male with a PMH remarkable for essential HTN, stable angina, and a 40 pack-yr smoking hx presenting with intermittent lower calf pain brought on by exertion x 1 week.

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1) Left Lower Calf Pain: Given the patients past medical history of essential HTN, long-standing smoking hx, and CHD (coronary heart disease), it is likely that this patients lower left calf pain is secondary to atherosclerosis. Its association with exercise, 5-minute duration, unilateral LE coolness, relief by rest, decreased left tibialis posterior pulse, and LE location are consistent with the classic symptoms of lower calf claudication. Moreover, this patient has 3 major risk factors that increase the likelihood of PAD (peripheral arterial disease) including cigarette smoking, hypertension, and hyperlipidemia. Neurological or muscular causes of lower leg pain are unlikely due to normal reflexes, sensation, muscular strength, gait, and absence of traumatic events. Plan: 1) Lifestyle and Diet Modifications to Decrease Risk Factors of CHD and PAD: Consult patient about smoking cessation, decreasing saturated fats in diet (e.g. fried foods), weight loss, reducing sugar intake (prediabetic), and continued walking regimen. 2) Antiplatelet Therapy: If patient is not already on ASA (aspirin), it should be prescribed to decrease the incidence of thrombosis and thereby, PAD events. 3) Follow-Up Care: Patient should RTC in 4 weeks to reevaluate progression of claudication. If symptoms persist and are severe, revascularization or administration of cilostazol (in the absence of heart failure) may be considered.

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