TABLE OF CONTENTS

Purpose of Handbook ......................................................................................... Page 2

Elements of the Patient Encounter ..................................................................... Page 3
Types of Patient Encounters ............................................................................... Page 4
Descriptors (Attributes of a Symptom) .............................................................. Page 5
Review of Systems ............................................................................................. Page 6
Example of a Normal Complete Exam ............................................................ Page 10
Example: Admission H&P ............................................................................... Page 13
Example: Outpatient H&P (1st Visit) ............................................................... Page 18
A Guide to Writing SOAP Notes ..................................................................... Page 25
Sample SOAP Note .......................................................................................... Page 29
Sample Pediatric SOAP Note ........................................................................... Page 30
Sample Inpatient Progress Note ....................................................................... Page 32
Behavioral Medicine Note Template ............................................................... Page 34
Sample Behavioral Medicine Note .................................................................. Page 35
Examples of Surgical Notes ............................................................................. Page 38
Examples of OB/GYN Notes ........................................................................... Page 41
Sample Procedure Notes .................................................................................. Page 53
Admitting Orders .............................................................................................. Page 55
Differential Diagnosis ...................................................................................... Page 57
Oral Presentations ............................................................................................. Page 59
Common OB/GYN Abbreviations ................................................................... Page 62
 PURPOSE OF HANDBOOK

The purpose of this handbook is to supplement the required textbook with clarification and
examples so that students will know what is expected of them. All students should read Bates
Guide to Physical Examination several times over the course of the didactic year and again
during the clinical year.

There is more than one correct way to perform some physical examination maneuvers and
variations in the method of obtaining and recording the history and physical examination. So
that students will all be working from the same standard, the method presented in Bates. Any
variations from Bates will be expressed to the students by faculty.

There is no one example or format that applies to all clinical situations. What must be done and
the manner in which it is recorded depends on the setting the patient is seen, the patient’s
presenting complaint and the information obtained in the history of present illness, past medical
history, social history and the patient’s vital signs and general appearance. The clinician must
use this information, think through this particular patient’s situation, and act accordingly.

The faculty is here to assist you in your learning. Comments made on papers are constructive
and are meant to help you understand the clinical process and develop clinical acumen.

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 ELEMENTS OF THE PATIENT ENCOUNTER

Location: The patient – provider interaction may take place in various locations.

Inpatient Setting: Inpatient visits take place inside the hospital where patients have been
admitted for at least an overnight stay. Most hospitals divide patients into medical, surgical,
pediatric, labor and delivery (L&D), and intensive care floors or sections.

Extended Care (Long Term Care) Facilities: These include nursing homes, rehabilitation
centers and skilled nursing facilities and may be connected with a hospital or free-standing.

Outpatient or Ambulatory Settings:

 Primary Care: Primary care in the ambulatory setting includes family practice, internal
medicine, pediatrics and women’s health care. The setting may be an office or other
health care center such as a community clinic. Providers care for both acute and chronic
patient problems as well as preventive care. There is emphasis on continuity of care.
 Consultant or Specialist: Provider of non-primary care services.
 Emergency Department: Section of the hospital that cares for out-patients with acute
conditions. Patients may typically arrive by ambulance or private transportation.
 Urgent Care Facility: May be connected with a hospital emergency department or may
be freestanding. Providers care for patients with acute problems.

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 TYPES OF PATIENT ENCOUNTERS

Complete History and Physical (H&P): When a patient is admitted to the hospital a complete
patient history and physical examination is performed by the provider. The written record* of
this encounter is called the Admission H&P and includes an assessment and plan in addition to
the history and physical. Subsequent encounters with the hospitalized patient are recorded as
inpatient progress notes.

Complete H&Ps (includes assessment and plan) are also done in the outpatient office or clinic
setting to obtain a complete database of information on a new patient who will be receiving
their ongoing care at this facility.

Episodic Visit: An episodic visit occurs in the ambulatory setting and is a visit that focuses on
the patient’s presenting problem (chief complaint). Therefore, in contrast to an H&P, not all
review of systems (ROS) questions are asked. The physical examination does not necessarily
involve every organ system but rather is determined by the presenting complaint and the present
illness (HPI). An episodic visit is recorded in the SOAP format.

* Only responses to questions asked and physical examination actually performed should be
recorded. If a portion of the physical examination is not done, appropriate documentation such
as “not examined” and reason why should be recorded for that portion of the examination. If a
portion of the history is not obtained, an addendum may be added at the end of the written
record stating the oversight. Example: “neglected to ask if there is any family history of colon
cancer, will do so next visit.”

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 DESCRIPTORS (ATTRIBUTES OF A SYMPTOM)

For every symptom (chief complaint and associated symptoms) the clinician should ask the
following descriptors: Start with most important as related to visit
1. The mode of onset of the symptom:
a. Description of events coincident with onset (what was happening when the
problem began; what led up to it)
b. The total duration of the symptom.
c. Whether the onset was insidious, gradual, rapid or sudden.
d. Whether there have been similar episodes in the past.
2. Precipitating or exacerbating factors. (What started it? What makes it worse?)
3. Relieving or ameliorating factors, (What makes it better?)
4. The character of the symptom (e.g., dull, pressure-like, tearing, sharp, or burning;
constant, intermittent, crampy, colicky, throbbing, shooting). Note: terms such as
“sharp” must be defined (“sharp” may mean severe, knife-like, very brief, like an ice
pick, etc.)
5. The location of the symptom or injury (if applicable). The description of the location
should be anatomically precise.
6. Radiation of the symptom (if applicable). Radiation is most often applicable to a
patient’s description of pain or other abnormal sensation.
7. Severity (generally on a scale of 1-10, e.g. 7/10)
8. Associated signs and symptoms (e.g., nausea, diaphoresis, dyspnea)
9. Patient’s concerns and effect of the symptom on normal daily activities.
10. Course of the symptom (steady, intermittent, getting worse? better?)

You may wish to use the mnemonic OPQRSTU, onset, pain/position/provocation/palliation,

quality/quantity, region, (location and radiation)/reoccurrence/relieving factors,
severity/site/setting, time/temporal relationships, usual activities.
*not all symptoms will require PQRST so will just need a detailed history*

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 REVIEW OF SYSTEMS

In general, a thorough review of systems is requesting information about the following over the
last 3 months:

General: general state of health/well being, sleep patterns, weight change (gain/loss),
weakness, malaise, fatigue, fever/chills
 Pediatric: weight loss/gain, chills, fever, diaphoresis, weakness, and hx of anemia

Skin: color/pigment changes, dryness, rashes, eruptions/hives, contact sensitivities, pruritus,

birthmarks, growths, sores, moles and any size or color changes, previous skin disorders (i.e.
eczema, psoriasis, skin cancers), hair distribution, change in texture of hair or nails, sun or
chemical exposure
Pediatric: rashes, hives, pruritus, easy bruising, change in hair/nail texture or color, hx of
eczema

HEENT:
Head: headaches, pain, trauma/ injuries, dizziness, LOC, syncope, stroke
Pediatric: head trauma, headache, fainting
Eyes: visual acuity, change in vision, corrective lenses/contacts, color blindness, diplopia,
blurring, double vision, auras, photophobia, halos, floaters, glaucoma, cataracts, injury/
trauma, excessive tearing (lacrimation), redness, pain, infection, discharge, irritation,
dryness, last eye exam
 Pediatric: lid lesions, eyebrow hair distribution, discharge, injection, lacrimation,
conjunctivitis, photophobia, hx of eye injury
Ears: hearing acuity, change in hearing, hearing aids, ringing (tinnitus), vertigo, dizziness, pain,
discharge, itching, cerumen impaction, ear infections
 Pediatric: external lesions/masses, ear trauma, discharge, hx recurrent otitis media or
externa
Nose/ Sinuses: trauma/injuries, epistaxis, discharge, pain, congestion, obstruction, frequent
colds, rhinitis/coryza, postnasal drip, sinusitis, allergies, septal deviation
 Pediatric: recent URI, frequent colds, sneezing, rhinorrhea, congestion, epistaxis,
allergies, hx nasal obstruction/injury, post nasal drip, snoring
Mouth/ Throat/ Pharynx/ Larynx: sores/lesions/ulcers, bleeding gums, condition of teeth,
dentures, burning/sore tongue, pain, sore throat, tonsillitis, tonsillectomy, change in taste, dry
mouth, hoarseness, voice changes, difficulty swallowing, last dental exam, brushing/flossing
habits
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  Pediatric: gingival bleeding, oral lesions, tongue discoloration, white plaques, number,
condition and location of any teeth, change in sound of cry, frequent sore throats, mouth
breather

Neck: limitation of motion, pain on movement, neck stiffness, growths/lumps, enlarged

thyroid/goiter, tenderness, hx of swollen glands, thyroid disease.
 Pediatric: masses, nodules, swollen glands, neck stiffness

Respiratory: cough, sputum, dyspnea, orthopnea, SOB, wheezing, hemoptysis, chest pain,
night sweats, asthma, chronic bronchitis, pneumonia, COPD, emphysema, TB or exposure,
pleurisy, occupational exposure, trauma, pneumothorax, last CXR and last PPD with results
 Pediatric: choking/coughing with feedings, difficulty breathing, hx of apneic episodes,
hx asthma or hyperactive airway disease, hx pneumonia

Breasts: lumps/masses, pain, redness, swelling, tenderness, changes with menses, dimpling of
skin, nipple inversion, discharge, practice regular Self Breast Exam (SBE), last mammogram
and results, any procedures

Cardiovascular: chest pain (type, location, radiation, diaphoresis, nausea), palpitations, SOB,
DOE, PND, cyanosis, orthopnea, murmurs, HTN, fainting/syncope, hx of rheumatic
fever/MI/diabetes/angina, # of pillows sleep with at night, dependent edema of extremities, calf
pain/claudication, cool extremities, cyanosis, last EKG/ stress test and results, varicosities,
thrombophlebitis, blood clot hx
 Pediatric: abnormal heart beat (felt by parents), hx heart murmur, congenital heart
abnormality, cyanosis, edema, easy fatigability, tachycardia

Gastrointestinal: appetite changes, food intolerance/idiosyncrasies, indigestion, heartburn,

belching, bloating, dysphagia, abdominal pain nausea/vomiting , hematemesis, hx of ulcers,
jaundice, hepatitis, cirrhosis, ascites, gallbladder disease, pancreatitis, diverticulitis, ulcerative
colitis, liver disease, change in pattern of bowel movements, increased flatulence, change in
stool color, consistency and caliber, diarrhea, constipation, steatorrhea (fatty, floating stools),
clay colored stools, rectal bleeding (hematochezia), melena, hemorrhoids, laxative or antacid
use, hernias, previous abdominal films (why, when, & results), last colonoscopy (age and pmh
dependent)
 Pediatric: description of appetite, vomiting – onset, type, frequency and relation to
feeding, hematochezia, hx of colic, congenital metabolic abnormalities, excessive flatus,

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 steatorrhea, diarrhea, constipation, abdominal pain, describe normal bowel movements –
number, color and character of stools, bleeding, pruritus ani, pica

Urinary: urine color, odor and clarity (pus/blood in urine), dysuria, oliguria, nocturia,
hematuria, frequency, urgency, hesitancy, dribbling, poor stream, urinary retention,
incontinence, hx of UTIs, nephrolithiasis, generalized edema, flank pain, any studies/tests and
results
 Pediatric: describe urine color, frequency, odor, stream, hematuria, hx of diaper rash,
enuresis, urinary control, UTI hx

Genitoreproductive:
Male: lesions/ulcers, penile discharge, pain, scrotal or testicular masses/swelling/pain, hernias,
prostate infections/problems, hx of STD exposure/treatment, serology test +/- (HIV/syphilis),
practices regular Testicular Self Exam, (The following may be covered here or in Sexual
History) impotence, erectile dysfunction, ejaculation difficulties, hx of fertility problems,
contraception, sexual satisfaction, libido, number of partners, ever raped/molested
 Pediatric: circumcision, undescended testicles, scrotal masses, lesions, discharge,
deformity, Tanner staging, (epi/hypospadia), hernias
Female: ulcers/lesions on external genitalia, pruritus, rash, vaginal discharge and, previous hx
STD exposure/treatment, serology test +/- (HIV/syphilis), hx of DES exposure, other vaginal
infections and treatment, dysmenorrhea, dyspareunia, pelvic pain or masses, last PAP smear and
results, age of menarche, interval between menses, duration and amount of menses, date of
LNMP, bleeding/spotting between periods (meno/metrorrhagia), PMS, age at menopause and
menopausal symptoms, HRT, postmenopausal bleeding, contraception and hx of BCP with #
of years, gravida (number of pregnancies), para - term deliveries; premature births/stillborn;
abortions/miscarriages; number of living children (G_ P_ _ _ _), multiple births, complications
during pregnancies/ deliveries, (The following may be covered here or in Sexual History)
difficulty with orgasms, sexual satisfaction, libido, sexual orientation, hx of fertility problems,
number of partners, ever raped/molested. Last mammogram.
 Pediatric: vaginal discharge, menstrual hx if appropriate, lesions

Musculoskeletal: limitation of movement, weakness, pain or stiffness in muscles/joints/bones,

muscle cramps/spasm, joint deformities, joint swelling/ warmth/ redness or crepitation, hx of
arthritis/gout/backache/Lyme disease, prior fx’s/ dislocations/ injuries/trauma, any studies and
results

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  Pediatric: congenital hip dislocation, joint swelling, pain or deformity, limitation of
movement, weakness/paralysis, limp or other gait abnormalities, “growing pains”, muscle
pain

Neurological: LOC, blackouts, convulsions, seizures, syncope, headache, dizziness, vertigo,

tremors, involuntary movements, localized weakness, numbness/tingling, paresthesias,
paralysis, muscle atrophy or tenderness, loss of recent/ distant memory, thought coherent,
aphasia, dysphonia, dysarthria, lack of or poor coordination/balance, gait abnormalities, ataxia,
hx of CNS infections, trauma hx, mood change/swings
 Pediatric: seizures, tremors, disorientation, irritability, LOC, convulsions, twitches, tics,
staring spells, bed wetting, changes in personality, behavior, motor coordination, patterns
of speech or development

Peripheral Vascular: pain in legs/calves/thighs/ hips while walking; varicose veins,

thrombophlebitis, hx of vein clots, swelling of legs, coolness of extremities, loss of hair on
legs/toes, cyanosis, ulcers, stasis pigmentation.
 Pediatric: swollen, cool or discolored extremities

Endocrine: thyroid problems and goiter, heat or cold intolerance, flushing, tremors,
diaphoresis, changes in voice/ hair/ skin, gum pigmentation change, striae, exophthalmos,
polyphagia, polyuria, polydipsia, change in body contour/ weight/ appetite, irregular menses,
impotence and sterility, steroid or hormone medication, diabetes/thyroid hx

Hematologic: weakness, hx of anemia, sickle cell trait/disease, hx of transfusions, how many

and reason/ reactions, hx of bleeding tendencies, spontaneous bleeding or excessive bleeding
from trauma/procedures, enlarged or tender lymph nodes, easy bruising, petechiae

Psychiatric: nervousness, behavioral changes, trouble with thinking, irritability, mood swings,
memory loss, anxiety, depression, phobias, insomnia, nightmares, disorientation, hallucinations,
paranoia, depersonalization, sleep patterns, impotence, frigidity, sexual disturbances,
suicidal/homicidal tendencies, prior psychiatric treatment/ hospitalization/ medications

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 EXAMPLE OF A “NORMAL” COMPLETE PHYSICAL EXAM

Vital Signs: BP: 110/76 RA, 110/74 LA sitting, P: 78 bpm, regular, RR: 18/minute, unlabored,
T: 99.2o F (PO-oral, PR-per rectum), Pulse Ox: 99% RA (Room air) Height: 5’10”, Weight:
170 lbs. BMI: 24.4
General Survey: WN/WD in NAD, cooperative, well-groomed, appears stated age and seated
comfortably on exam table in no apparent distress. No treatment in progress. (This last phrase
is only used in the inpatient setting)
Skin: No rashes or lesions. No nail changes. Warm, dry, color good. Good turgor.
Head: Normocephalic, atraumatic (NC/AT). Hair distribution full, average texture, scalp
without lesions or tenderness.
Eyes: VA: 20/30 OS, 20/40 OD, 20/30 OU (corrected). Lids symmetrical without lesions, no
ptosis. Lash and brow distribution normal. Sclera anicteric, conjunctivae clear B/L. No D/C.
PERRLA, EOMI. Fields intact by confrontation. Red reflex present bilaterally. Cornea/lens
without opacities. Fundi without hemorrhages, exudates, A-V nicking, arteriolar narrowing.
Discs flat with sharp margins.
Ears: Auricles/tragi symmetrical without lesions/deformities, non-tender B/L. Canals clear and
without erythema B/L. TMs pearly grey, mobile, with landmarks and light reflex intact B/L.
Normal whisper test B/L. Rinne test AC>BC B/L. Weber test lateralizes to both ears.
Nose/Sinuses: No nasal deformity or swelling. No tenderness. Nares patent B/L, septum
intact without deviation. No septal hematoma. Mucosa pink, turbinates non-edematous, no
D/C. No maxillary or frontal sinus tenderness. Normal transillumination.
Mouth/throat: Lips pink without lesions. Buccal mucosa pink, moist without lesions. Good
dentition, no caries. Gingivae without lesions or discoloration. Tongue midline, no lesions are
seen or palpated on tongue. Tonsils and pharynx without erythema or exudate. Tonsils not
enlarged. Uvula midline. Uvula rises symmetrically, gag reflex intact.
Neck: Supple. FROM. No spinal tenderness. No lymphadenopathy of pre/postauricular,
occipital, tonsillar, submandibular, submental, superficial/deep cervical or supraclavicular
nodes. [Or, if some palpable but not enlarged, “submandibular nodes 1 cm bilat; post. cervical
nodes tender]. Trachea midline. Thyroid smooth, not enlarged [or not palpable], non-tender.
Thorax/Lungs: No deformity. Normal AP to lateral diameter. Symmetrical excursion
bilaterally. No chest wall tenderness. Percussion and tactile fremitus equal b/l. Resonant
throughout. Breath sounds vesicular, symmetrical and without rales, rhonchi or wheezing B/L.
Cardiovascular: No lifts, heaves, visible pulsations. No thrills. PMI 2 cm in L_ 5th ICS. Rate
and rhythm regular, S1 & S2 clear. No murmur, gallop or rub. Neck veins nondistended at 30o.
Breasts:

10
  Female: No dimpling, erythema, discoloration, or retractions. No nipple inversion or
discharge. No palpable dominant masses. No tenderness. No axillary, epitrochlear or
supra/infraclavicular lymphadenopathy.
 Male: No gynecomastia, erythema, discoloration, masses or discharge. No tenderness.
No axillary or supra/infraclavicular lymphadenopathy.
ABD: Non-distended. No scars, lesion or visible pulsations. No caput medusae. BS
normoactive X 4. No bruits. Soft, nontender, no masses palpated. No rebound, guarding. No
hepatosplenomegaly to percussion/palpation. Liver span XX cm in R midclavicular line. No
CVA tenderness.
Rectal: No external hemorrhoids or lesions. Good anal sphincter tone. [In MALE comment
on prostate- normal size, firm, non-tender and without nodules.] Trace soft brown stool present
in vault, FOB (or guaiac) negative.
Genital:
 Male: (Un)circumcised. No penile lesions or discharge. No scrotal nodules, masses,
swelling, varicosities or tenderness. Testes non-tender, smooth and present x 2. No
inguinal lymphadenopathy. No hernia. [In children, mention hypo/epispadias and
whether testicles have descended]
 Female:
o External – No lesions, masses or swelling.
o Vaginal-No discharge, no blood in vault. Vaginal mucosa moist. Cervix-
nulliparous/multiparous without lesions or discharge. Closed. No cervical motion
tenderness (CMT).
o Bimanual- Uterus- Non-tender and of normal size (vs. gravid), shape and
consistency. Adnexa – Non-tender without palpable masses B/L (or adnexa not
palpable). No inguinal lymphadenopathy.
o Note: it is abnormal to palpate ovaries in a post-menopausal female.

11
Peripheral Vascular: No edema of feet and ankles. No varicosities. No discoloration,
pigmentation changes, ulcers or lesions. No calf tenderness. Pulses:

Carot. Brach Rad. Ulnar Fem. Popl. DP PT

.
not
R
_ 2+ 2+ 2+ 2+ 2+ palpable 2+ 2+

L
_ 2+ 2+ 2+ 2+ 2+ not 2+ 2+
palpable

Musculoskeletal: No deformities, wasting, atrophy, swelling. Normal color and temperature.

No bony or soft tissue tenderness. Full ROM without tenderness in hands, wrists, elbows,
shoulders, spine, hips, knees, ankles. Strength 5+/5+ bilat, upper/lower. No scoliosis or
excessive kyphosis/lordosis. [CAUTION: do not write “full ROM” or “FROM” unless you
have tested the full ROM of all joints. It is not sufficient for the extremities to “look okay;” the
term “FROM” is only to be used when full range of motion has been examined].
Neurological:
 Mental status: Alert and oriented X3, cooperative, pleasant. Affect appropriate, thought,
speech and language coherent. Short- and long-term memory, abstract thinking and
calculation intact.
 CN: (see EENT)
o I - not tested
o II, III, IV, VI, VIII - see EENT
o V- facial sensation intact; masseter/temporal muscles intact.
o VII - face symmetrical at rest & with expression
o IX & X - no hoarseness, gag intact, palate/uvula rise symmetrically
o XI - SCM/trapezius strength intact bilateral
o XII - no dysarthria, tongue weakness/fasciculation
 Motor: Normal muscle bulk/tone. Good posture. Strength 5+/5+ upper & lower
extremities.
 Sensory: Sensation to light touch, pain, vibration, proprioception, and stereognosis intact
to trunk and bilaterally to both upper and lower extremities. Normal two point
discrimination.

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  Cerebellar Function: Normal gait including tandem, heel and toe walking. Romberg
and pronator drift negative. Normal rapid alternating movements and point to point test.
 Reflexes: No clonus
Biceps Triceps Brachio Abd Patella Achille Babins
s ki
RT 2+ 2+ 2+ 2+/2+ 2+ 2+ 
LT 2+ 2+ 2+ 2+/2+ 2+ 2+ 

EXAMPLE - ADMISSION H&P NOTE

PA student admitting note

11/28/14 11:00 am
Patient: A.M., 36 year old male MR#55006
Source: Self, seems reliable

CC: “I have pain in my left leg” x 4 days

HPI: 36 y/o male with history of left leg DVT X2 c/o L leg pain x 4 days. Pt reports sudden
onset of L leg pain located in calf with occasional radiation to L knee 4 days ago. Pain
described as “an ache” and severity is 7/10. It is constant and is worse with standing and
ambulation. Took Tylenol with codeine he had in house with some decrease in severity of pain.
Associated swelling of L leg which has gotten progressively worse over past 4 days. Has not
noticed any change in color or temperature of skin of leg. Denies hair loss on extremities.
History of 2 episodes of DVT, left leg 1994 and 1995. Hospitalized and treated with heparin
followed by Coumadin X 6 months. Patient concerned he has a recurrence. Previous IVDU
injecting into veins of L leg and arm. No IVDU for 6 years. Pt is on methadone maintenance X
6 yrs,

Denies fever, chills, cough, CP, palpitations, SOB, DOE, hemoptysis, paresthesias, loss of hair
to extremities, pigmentation changes, ulcer formation, limitation of movement, weakness,
stiffness to joints, joint swelling, preceding trauma, inactivity, recent travel, or prolonged bed
rest. Denies hx. of surgeries or neoplasms.

PMH:
Childhood Illnesses: Chickenpox age 10, no complications or sequellae. Denies h/o MMR,
rheumatic fever.
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Adult illnesses: DVT x2 – LLE 1994 and 1995
Denies history of skin infections, sepsis, arthritis, HIV disease, hepatitis, pulmonary embolus,
MI, CAD, CHF, HTN, Hypercholesterolemia, DM or other illnesses.
Hospitalizations:
DVT LLE: 1994 at Our Lady of Mercy Medical Center, 14 days, treated with IV heparin
and then Coumadin for 6 months
DVT LLE: 1995 at Westchester Square Hospital, 7 days, treated with heparin followed
by Coumadin
Surgeries: Denies
Medications: Methadone 70 mg/day at Albert Einstein for h/o heroin addiction
Tylenol with codeine #3 prn for pain
No OTC medications
Allergies: NKDA, NKFA, NKEA
Accidents/Injuries: Denies
Immunizations: Had childhood series, had hepatitis series and last tetanus booster 1year ago at
Albert Einstein, Flu vaccine 9/2014
FH: Mother died age 60 of heart disease (specifics unknown)
Father alive, age 68, emphysema
Brother, age 38 A with HTN
Sister, age 34, A/W
No children
All grandparents deceased, causes unknown to patient
Denies known FH of DM, asthma, arthritis, cancer, kidney disease, epilepsy, tuberculosis or
mental illness.
SH: Born and raised Queens, NY. Finished high school. Works intermittently as construction
worker. Lives alone in studio apartment. Financially with no savings and lives pay check to
pay check. Only exercise is what he gets on the job. Eats 3 meals a day: breakfast = cereal and
fruit, lunch = sandwich, chips and soda, dinner = meat, potatoes, vegetables. Sleeps 7-8
hours/night. No religious affiliation. Does not feel he has a lot of stress in his life. Single,
never married, states he has lots of friends. Sexually active, exclusively heterosexual, 4
partners past year, oral and vaginal sex, uses condom intermittently. Smokes 1ppd x 23 years.
Drinks 5-6 beers/week. Heroin IVDU 2000-2010. Also smoked marijuana and snorted cocaine
during that time. Methadone maintenance 2011-current.

ROS:
General: See HPI. No weakness, weight changes, fatigue.

14
Skin: Denies dryness, rashes, pruritus, lesions, color or pigment changes, changes in hair
distribution
Head: Denies headaches, trauma, dizziness, syncope.
Eyes: Denies visual changes, diplopia, blurring, halos, floaters, pain, redness, discharge,
photophobia, or pruritus. Has never had eye exam.
Ears: Denies changes in hearing, dizziness, pain, itching, tinnitus, vertigo or history of ear
infections.
Nose/sinuses: Denies trauma, congestion, discharge, infections, epistaxis, hay-fever or frequent
colds.
Mouth/throat: Denies sores, bleeding gums, lesions, bleeding gums, sore tongue, hoarseness,
voice changes, difficulty swallowing or frequent sore throats. Last dental exam 1 yr ago.
Neck: Denies limitation of movement, pain, lumps, swollen glands or h/o thyroid disease.
Breasts: Denies redness, swelling, changes to skin or nipples, lumps, pain or discharge.
Respiratory: See HPI. Denies wheezing, orthopnea, night sweats, asthma, pneumonia, TB or
PE. Last CXR 1995, normal.
Cardiac: See HPI. Denies history of heart trouble, HTN, rheumatic fever, endocarditis, heart
murmurs.
GI: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, appetite changes,
indigestion, heartburn, melena, hematochezia, jaundice, pancreatic, gallbladder or liver disease.
Urinary: Denies frequency, dysuria, oliguria, nocturia, urgency, hesitancy, dribbling, urinary
retention, incontinence, hematuria or recent flank pain.
Genital: See SH. Hx of GC 1990 treated with “shot and pills”. Denies penile discharge, sores,
testicular masses, hernia, impotence, changes in libido or pain. Does not do self-testicular
exam. No hernias.
Peripheral Vascular: See HPI. Denies cyanosis of extremities.
MS: See HPI. Denies joint pains, gout, back pain, or history of arthritis.
Neurologic: Denies memory changes, LOC, headache, dizziness, involuntary movements,
weakness, gait abnormalities, fainting, seizures, motor or sensory loss.
Hematologic: Denies easy bleeding, bruising, h/o anemia.
Endocrine: Denies heat or cold intolerance, flushing, pigment changes, striae, polyuria,
polydipsia, changes in weight, changes in menses, excessive sweating.
Psychiatric: Denies hallucinations, irritability, memory changes, phobias, changes in sleep
patterns, insomnia, nervousness, mood changes or depression, no suicidal or homicidal ideation.

Physical Exam:
Vitals: BP 122/80 right arm sitting, P 90bpm regular, R 16/minute unlabored, T 97.5 F(PO) ,
Ht. 6’0”, Wt 202 lbs, Pulse Ox: 99% on RA
15
General: Well nourished, appears stated age, cooperative A&Ox3, NAD. No treatment in
progress.
Skin: Skin on posterior aspect of left calf with mild erythema from just below the knee to just
above the ankle, edema and increased warmth as compared with right. No other rashes or
lesions. Good skin turgor. No nail changes.
Head: Normocephalic, atraumatic (NC/AT), hair of average texture, scalp without lesions.
Eyes: Vision 20/20 OD, OS and OU (uncorrected) using pocket card. Lids without lesions, no
ptosis. Visual fields full by confrontation. Palpebral conjunctiva pink B/L. Sclera white (B/L).
Pupils equal, round, regular, equal, react to light (PERRL). EOMs intact.
Fundoscopic: + red reflex, no corneal opacities. Disc margins sharp. No arterial narrowing,
hemorrhages or A-V nicking.
Ears: Auricles without deformity, lesions or tenderness. Canals clear B/L. TMs gray, intact,
mobile, and with visible landmarks, good light reflex bilaterally. Acuity to whispered voice
good. Rinne test AC>BC B/L. Weber test lateralizes to both ears.
Nose/Sinuses: Mucosa pink, turbinates non-edematous, septum intact and midline without
deviation, nares patent without obstruction. No sinus or nasal bone tenderness.
Mouth/Pharynx: Mucosa pink, moist. No lesions. Teeth in good repair, no caries. Uvula and
tongue midline. Uvula rises symmetrically, gag intact. Tonsils not enlarged, pharynx without
erythema or exudate.
Neck: Supple, FROM, non-tender. Trachea midline. Thyroid smooth, non-enlarged.
Lymph Nodes: Small (<1 cm) soft, nontender, mobile, anterior cervical nodes. No posterior
cervical, occipital, auricular, supraclavicular, axillary or epitrochlear nodes palpated. Small
inguinal nodes palpated bilaterally.
Thorax and Lungs: Thorax symmetrical. Good expansion. No chest wall tenderness. Lungs
resonant. Percussion equal b/l. Breath sounds vesicular, symmetrical with no wheezes, rhonchi
or crackles B/L.
Cardiovascular: Neck veins nondistended at 300. Carotid upstrokes brisk, symmetrical, 2+
and without bruits. No heaves or thrills. PMI palpable in 5th ICS, midclavicular line.
Clear S1 and S2 without murmur, gallop or rub.
Breasts: No lesions, rashes, discoloration, gynecomastia, masses, tenderness or nipple
discharge.
Abdomen: Protuberant. No scars, discoloration or visible pulsations. BS normoactive X 4.
No bruits. Liver span 10 cm in R midclavicular line with liver edge palpable at R costal
margin. Splenic percussion negative. No tenderness or masses. No rebound or guarding. Spleen
and kidneys not felt. No CVA tenderness.
Rectal: No external hemorrhoids or lesions. Good sphincter tone, no tenderness.
Prostate smooth, normal size and consistency. No masses. Brown stool present, FOB negative.
16
Genitalia: Circumcised, no penile lesions or discharge. Testes non-tender, descended X2
without masses. No inguinal hernias
Peripheral vascular: See skin. Mild L calf tenderness to palpation. Mild edema of L leg
below knee, non-pitting. L thigh 50 cm, R thigh 48 cm (measured 8 cm above knee). L calf 43
cm, R calf 37 cm (measured 8 cm below knee). Positive Homan’s sign on L. No tenderness to
palpation above knee. No varicosities. No cords palpated. Decreased hair growth noted on
toes and dorsum of L foot as compared to R. Pulses: Radial 2+ R and L, femoral 2+ R and L,
DP 2+ R and L, PT 2+ R and L. Popliteal pulses not palpable.
Musculoskeletal: No joint deformities or swelling. No bony tenderness with FROM in hands,
wrists, elbows, shoulders, spine, hips, knees, ankles.
Neurologic: A&Ox3, cooperative, thought and speech coherent. Short- and long-term
memory, abstract thinking and calculation intact.
Cranial nerves: See eyes, ears, mouth/throat exams, also:
I - not tested
V - sensation intact, strength good
VII – facial movement good
XI – sternocleidomastoids and trapezii strong
Motor intact with normal muscle bulk and tone. Strength 5/5 throughout. Rapid alternating
movements and point-to point movements intact. Gait normal. No pronator drift.
Romberg negative. Pinprick, light touch, position, vibration and stereognosis intact. No
clonus.

Reflexes:
Biceps Triceps Brachio- Patellar Achilles Plantar
radialis (Babinski)
R 2+ 2+ 2+ 2+ 2+ 
L 2+ 2+ 2+ 2+ 2+ 

Tests: Venous Doppler b/l lower extremities shows thrombus extending to left common
femoral.
EKG: NSR at 70 beats/min.

A: 1. DVT extending to L common femoral

2. Hx of recurrent left leg DVT
3. Hx of IVDU, currently on methadone maintenance
4. Smoker

17
P: 1. CBC with diff., UA, chem7, ALT, AST, CA, T. protein, albumin,
cholesterol, PT, PTT
CXR
Heparin 25,000 units in 500 cc of D5W @ 1000cc/hr
Repeat PT, PTT after 6 hours.
2. Vascular surgery consult for consideration of vena cava filter due to recurring
nature
3. Methadone maintenance after contacting program @ Albert Einstein
4. Smoking cessation to be addressed later
5. Address HCM on discharge
6. Patient educated on possible side effects of medications, possible risks involved
with anticoagulation therapy including bleeding. Diagnosis and probable course of
treatment and therapy along with need for tests and medications thoroughly
discussed with patient. Pt verbalized understanding.

Printed PA student name and signature

EXAMPLE H&P – Outpatient **1st visit**

4/7/2015 2:15 PM
Patient: C.R., 39 yo ♂ MR #87694
Source: self, seems reliable

CC: “Lower back pain” x 3 months

39-year-old male presents c/o LBP x 3 months. Pt reports insidious onset of dull, aching b/l
low back pain almost daily for the past 3 months. States pain is more severe in AM and
decreases somewhat within the hour after he arises. It continues intermittently throughout the
day, at times radiating down L leg past knee. Pt rates pain from a 4-8/10 throughout the day.
Associated L leg pain is sharp and stabbing and then subsides, ranging from a 6-8/10,
aggravated by motion or activity such as lifting, twisting or bending and by coughing, sneezing
and remaining in one position for a long period of time. Partially relieved by rest, ibuprofen
(taken 3-4x per week) and stretching exercises (done 2x daily). Works in management and does
not recall any episode of twisting, over exertion or strain which may have precipitated pain.

18
Denies fever, weight changes, abdominal pain or masses, n/v, dysuria, hematuria, frequency,
hesitancy, h/o nephrolithiasis, bowel or bladder incontinence, hip pain, paresthesias, history of
injury or fall, h/o MVA, Denies history of nephrolithiasis,

Childhood Illness: Recalls h/o measles, mumps and chicken pox, no sequelae or complications.
Denies h/o scarlet fever, pertussis, rheumatic fever or rubella. Adult Illness: Denies TB,
hepatitis, HTN, DM, CVA, cancer, emphysema or any psychiatric illness.
Hospitalizations/Surgeries: Denies
Medications: OTC ibuprofen 200 mg 2-3 tabs PO QD 3-4x per week. (Last dose 4-6-15 400
mg in PM.)
Multivitamins 1 tab QD
Denies any other medications including OTC medications.

Allergies: NKDA, NKFA, NKDA.

Immunizations: Pt. recalls DPT, polio and MMR. Never immunized for Hep B. Cannot recall
tetanus booster within last 5 years. PPD neg 2012. Flu 9/2015

FH: ↑ Mother, 71 y/o type 2 DM

↑ Father, 70 y/o hx MI at 55 y/o, arthritis
↑Brother, 40 y/o HTN
↓Sister, 37 y/o Down’s Syndrome
↓MGM, 75 y/o diabetic coma
↓MGF DEC 84 y/o cerebral aneurysm
↓PGM, 70 y/o unknown
↓PGF DEC 75 y/o unknown
Denies FH of MI, CAD, HTN, DM, CVA, CA, anemia, mental illness.

Social: Patient is a single Catholic male of German-Irish descent born in Queens, New York.
Denies military experience and lives alone. Employed by Verizon for the past 18 years
currently in management position. Travels frequently in the Northeast US for computer
training. Regular meals 3x a day including meat, vegetables and fruits, drinks about 4 cups of
coffee daily. Regular exercise 3-4x a week. Reports occasional insomnia. Cigarette smoker x
10 years 4-5 packs per week, quit in 1992. Relates use of cocaine, amphetamines and marijuana
“recreationally” during his 20s. No illicit drug use past 10 years. Drinks alcohol “socially” 3-4
drinks 3x a week. Pt. is exclusively homosexual and states he has always practiced safe sex.

19
Has had protected sex with a total of 4 partners. Denies any sexual dysfunction and is not
sexually active x 8 mos.

ROS:
General: See HPI. Denies chills, weakness, fatigue, or night sweats
Skin: Denies dryness, rashes, pruritus, lesions, color or pigment changes, changes in hair
distribution
Head: Denies headaches, trauma, dizziness, syncope.
Eyes: Denies visual changes, diplopia, blurring, halos, floaters, pain, redness, discharge,
photophobia, or pruritus. Has never had eye exam.
Ears: Denies changes in hearing, dizziness, pain, itching, tinnitus, vertigo or history of ear
infections.
Nose/sinuses: Denies trauma, congestion, discharge, infections, epistaxis, hay-fever or frequent
colds.
Mouth/throat: Denies sores, bleeding gums, lesions, bleeding gums, sore tongue, hoarseness,
voice changes, difficulty swallowing or frequent sore throats. Last dental exam 1 yr ago.
Neck: Denies limitation of movement, pain, lumps, swollen glands or h/o thyroid disease.
Breasts: Denies redness, swelling, changes to skin or nipples, lumps, pain or discharge.
Respiratory: See HPI. Denies wheezing, orthopnea, night sweats, asthma, pneumonia, TB or
PE. Last CXR 1995, normal.
Cardiac: See HPI. Denies history of heart trouble, HTN, rheumatic fever, endocarditis, heart
murmurs.
GI: See HPI. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, appetite
changes, indigestion, heartburn, melena, hematochezia, jaundice, pancreatic, gallbladder or
liver disease.
Urinary: See HPI. Denies oliguria, nocturia, urgency, dribbling or urinary retention.
Genitoreproductive: Denies STDs, discharge, lesions, erectile dysfunction, scrotal masses or
hernias.
Musculoskeletal: See HPI. Denies paralysis, joint pain/stiffness/swelling, arthritis, muscle
cramps/weakness or any deformities.
Neurologic: Denies memory changes, LOC, headache, dizziness, involuntary movements,
weakness, gait abnormalities, fainting, seizures, motor or sensory loss.
Hematologic: Denies easy bleeding, bruising, h/o anemia.
Endocrine: Denies heat or cold intolerance, flushing, pigment changes, striae, polyuria,
polydipsia, changes in weight, excessive sweating.

20
Psychiatric: Denies hallucinations, irritability, memory changes, phobias, changes in sleep
patterns, insomnia, nervousness, mood changes or depression., no suicidal or homicidal
ideation.

Physical Exam:
Vitals: BP L _ arm sitting 120/70, Pulse:72 bpm, regular, RR: 16 / min, unlabored, T: 98.4 F
orally, HT 5’11”, WT 155 lbs.
General: Sitting in chair, appears uncomfortable and in no acute distress. Well groomed/well
nourished and appropriately developed. Cooperative with exam.
Skin: Normal color and texture. Adequate mobility and turgor. No scars, rashes or bruises.
Bilateral skin temperature normal all extremities.
Head: Normocephalic without evidence of trauma. No areas of tenderness or scalp lesions.
Hair distribution full with average texture with good luster. No abnormal facies.
Eyes: Visual acuity 20/20 OS/OD/OU with pocket vision chart and corrective lenses. Eyebrows
normally distributed. No erythema or ptosis of lids. Conjunctivae pink without injection or
discharge, sclera white. Visual fields full by confrontation, EOMs intact. PERRLA.
Fundoscopic: pos. red light reflex OU, no opacities of lens and cornea, discs yellow, flat with
sharp margins. No A-V nicking, hemorrhages, cotton wool patches or exudates.
Ears: No swelling, discoloration or lesions B/L. Auricles/tragus nontender B/L. Canals
without cerumen, injection or discharge. TM’s gray, intact with normal landmarks and good
light reflex B/L. Acuity to whispered voice intact.
Nose/sinus: No swelling, discoloration, rashes or deformity. No septal deviation or perforation.
Nares patent, mucosa pink B/L. Turbinates without erythema or edema. No nasal bone
tenderness. Maxillary and frontal sinuses nontender.
Mouth/throat: Mucosa moist, pink without plaques, ulcers or lesions. Dental hygiene good
with no gingival erythema. Tongue with normal papillae and no lesions. Uvula/palate rise
symmetrically. Tonsils atrophied. Pharynx without erythema or exudate. Uvula midline.
Neck: Symmetric without masses or scars. Supple with FROM. Trachea midline with no
deviation, rises well with swallowing. No palpable thyromegaly. No pre/postauricular,
occipital, tonsillar, submandibular, submental, superficial or deep cervical or supraclavicular
lymphadenopathy.
Chest/lungs: No evidence of respiratory distress. No lesions, discoloration or rashes.
Excursion symmetrical. Chest wall nontender. Lungs are resonant throughout. Percussion
equal b/l. Breath sounds are vesicular, symmetrical, with no crackles, wheezes, rhonchi or
pleural rubs B/L.
Cardiac: No visible lifts, heaves, pulsations. No JVD. No thrills. PMI 2 cm at 5th ICS, L _
MCL. S1, S2 distinct. No S3, S4. No murmurs or rubs.
21
Breast: No lesions, rashes, discoloration, gynecomastia or mass. No tenderness. No nipple
discharge.
Abdomen: Normal contour without protuberance, bulging or visible mass. No angiomas or
caput medusae. Minimal aortic pulsation noted with no visible peristalsis. BS normoactive X
4. No aortic, renal or femoral bruits. Tympanic over gastric air bubble and R _ colon. Liver
span 7 cm at R
_ MCL. Splenic percussion sign neg. Soft, nontender with light/deep palpation.
No rebound or guarding. No mass, hepatosplenomegaly, aortic widening. No CVA tenderness.
Rectal: No external lesions. Sphincter tone good. Prostate non-tender, firm, rubbery, and
without enlargement or nodules. No rectal mass. Soft, brown, guaiac neg., stool in ampulla
GU: Circumcised without lesion, rashes or urethral D/C. Testes without mass/tenderness. No
inguinal hernia.
PV: No cyanosis, rubor or pallor. No lesions, ulcerations, edema or varicosities. Cap. refill < 2
sec. Hands, feet warm to the touch. No carotid bruit.
Pulses:

Carot. Brach Rad. Ulnar Fem. Popl. DP PT

.

R 2+ 2+ 2+ 2+ 2+ not 2+ 2+
palpabl
e

L
_ 2+ 2+ 2+ 2+ 2+ not 2+ 2+
palpabl
e

Lymph nodes: No supra/infraclavicular, axillary, epitrochlear, inguinal or femoral

lymphadenopathy.
MS: Stands and walks without difficulty. Gait smooth, symmetrical. No erythema, swelling or
effusion of joints. No tenderness or crepitation of any joint. No atrophy/wasting or muscle
fasciculation of lower extremities. FROM, passive and active, of hands/fingers, wrists, elbows,
shoulders, hips, knees, ankles. C-spine without spinous process or paravertebral muscle
tenderness, FROM. T-, L- and S-spine show no scoliosis, excessive lordosis/kyphosis or
obvious deformity. Iliac crests even in height. Moderate left lumbar paravertebral muscle and
lumbar-sacral joint tenderness. Spinous processes not tender. Lateral bending - R _ fingertips 2
cm past joint line, L
_ 3 cm above joint line. Flexion full, rotation decreased on left, flexion stops

22
with fingertips 10 cm above toes due to pain. SLR with non-radiating pain left leg at 50
degrees, none on right. Negative Hoover test.
Neuro:
Mental status: Alert, cooperative, pleasant, oriented x 3. Affect appropriate, thought coherent.
Short- and long-term memory, abstract thinking and calculation intact.
CN: (see EENT)
I - not tested
V - facial sensation intact; masseter/temporal muscles intact.
VII - face symmetrical at rest & with expression
IX & X - no hoarseness, gag intact, palate/uvula rise symmetrically
XI - SCM/trapezius strength intact bilat.
XII - no dysarthria, tongue weakness/fasciculation
Motor: Normal muscle bulk/tone. Strength 5+/5+ upper & lower extremities. RAM, point-to-
point movements intact. Gaits (natural, tandem, heels, toes) intact.
Sensory: Romberg neg. Sensations of pain, light touch, proprioception, vibration and
stereognosis intact. No clonus.
Reflexes:
Biceps Triceps Brachio-radialis Patellar Achilles Plantar
(Babinski)
R 2+ 2+ 2+ 2+ 2+ 
L 2+ 2+ 2+ 2+ 2+ 

Assessment:
1) Subacute lumbar/sacral and sacroiliac pain, probably muscular
Consider nerve root impingement or arthritic process if symptoms worsen or
unresponsive to conservative management
2) Behind on Health Care Maintenance

Plan:
1) Naproxen 1 tab q12 hours, take with food. Flexeril 10mg TID prn pain. Physical therapy
evaluation of stretching exercise regimen and ergonomics at work Suggest seeing
Worker’s Comp provider if any special accommodation needed for seating at work. Re-
evaluate in 1 mo. If no improvement, L/S films; if more suggestion of nerve root
impingement consider MRI. Return or call if increased pain, radiation, paresthesia or
weakness. Go to ER for worsening of condition especially incontinence.
2) Td booster today. Apply PPD R _ ant forearm, RTC 48 h. to read. Explained reasons and
procedure for TSE. Fasting chem7 screen/lipids, plus CBC/diff, ESR prior to next visit.
23
 3) Explained probably diagnosis in detail and plan for re-evaluation and possible further
work up. Patient education on side effects of medications including increased risk of GI
and renal disease. Discussed importance of physical therapy and need to strengthen back
muscles. Pt understood and agrees with above noted patient education and plan.
4) RTO 1 week sooner if worse

Printed names with title and signatures

24
 A GUIDE TO WRITING SOAP NOTES

Definition: A SOAP note is an organized written recording of an episodic patient contact.

This is not to be confused with a complete history and physical.

Meaning of the abbreviation SOAP:

S = Subjective: This is the history of the current problem. It is important to record only data
communicated to you by the patient in the subjective portion of the note. It is
preferable to put what the patient communicates to you into medical
terminology or if emphasis is required, patient’s quoted own words can be
utilized.

O = Objective: This is where you record the physical examination and lab data. Only data
gathered by your observation should be in the objective.

A = Assessment: This is a list of the patient's problems that you compile from the
subjective and objective data and may include a differential diagnosis

P = Plan: This is a list of what you are going to do about the problems in the
Assessment. Assessment and Plan can be combined into A & P where the
plan is recorded after each assessment.

Organization of a SOAP note:

The format of a SOAP note is always organized as follows:
Patient Identification (Pt. ID)
Chief complaint (CC)
S
O
A
P

Basic guidelines to consider before putting-pen to paper:

A.) Always consider the differential diagnosis of a problem and assure that your SOAP note
contains a sufficient amount of information so that it is evident to the reader that you
have entertained all the possible reasons for the existence of the problem.

25
 B.) Be thorough. An incomplete SOAP note is an indication of a poor patient contact and an
unsafe approach to patient care. A long note is not necessarily thorough, and conversely
a short note may be thorough.
C.) Be professional. Remember that you are writing a document that is going to be a
permanent part of the patient's record subject to review by other health professionals and
possibly by the courts. Spelling, penmanship, and organization are important.

Putting the SOAP together (refer to sample SOAP note as you go through this section):
Patient identification (PT. ID): This section should include the name, age and sex of the patient.
Other information such as date of birth (DOB), address, phone number or chart number are also
be included.

Chief Complaint (CC): The chief complaint is like the title of a short story. It is most often in
the patient's own words followed by duration. It should be short.
Examples:
i. "I have a terrible headache" X two days
ii. “I fell and hit my head five hours ago”
If the patient does not have any complaint, the cc becomes the reason for the visit.
Examples: “I need a complete physical for my job”
i. F/U (follow-up) on hypertension, (HTN)
ii. F/U on abnormal liver enzyme tests

Subjective: Present Illness (also referred to as History of Present Illness or HPI)

Start with the descriptors. By asking all these questions every time you encounter a patient
problem, and by documenting the answers in the subjective, the case will become clearer and
easier to handle. The descriptors will also guide which review of systems you will want to
cover. Risk factors and social history should be included in the history of present illness if they
relate to the chief complaint. Example: If the chief complaint is “I have a cough” x 1 week, the
patient’s smoking status should be included in the HPI rather than later in the patient profile.

If the patient has multiple problems you must use the descriptors to describe each complaint
separately, unless you recognize the multiple problems as manifestations of a single syndrome.

Descriptors must be followed by PERTINENT NEGATIVES.

1) Next is the Past Medical History which must include:

a. Adult Illnesses
26
 b. Hospitalizations/Surgeries
c. Medications
d. Allergies
e. Shx
Other components of the PMH that are not listed above only need to be addressed if pertinent to
the CC.

Objective:
 Vital signs come first - remember, they are vital
 General appearance is always next. This is your opportunity to paint a picture of the
patient so the reader has an understanding of the patient’s appearance and condition.
 Rest of the physical exam appropriate to the problem (focused PE).
 A good rule of thumb is to examine each system that you reviewed in the subjective
section. Often this is one system anatomically above, and one system anatomically
below the system involved in the chief complaint. There is a definitive order for
reporting the physical exam (the head down). In the beginning you must detail your
exam- “normal" and “clear” are not acceptable.
 Lab data and diagnostic studies are included in the objective portion. These are only
results, which you have already collected - not what you plan to do. Any stat labs
should be reported here

Assessment: This is where you list all the problems you have identified in the subjective and
objective. This can include:
o Acute Problem
o Chronic Problem
o Any abnormal signs and symptoms (that are NOT related to acute problem)
o Lab Abnormalities (that are NOT related to acute problem)
o Social Issues
o Health Care Maintenance (HCM)

Prioritize your assessment, putting the most likely first. At times you will want to put a life-
threatening diagnosis toward the top of your list if it is a realistic possibility.

In the Assessment, various modifications are used to describe the probability of your
assessment. Examples:
 Pneumonia
 Probable pneumonia
27
  Possible pneumonia
 Pneumonia vs. bronchitis
 Probable acute CHF vs. exacerbation of COPD
 R/O pulmonary embolus
 R/O pneumonia

Only use the modifier rule out (R/O) if you are going to do something that can eliminate with
good probability the diagnosis you are considering.

Other modifiers can be used such as, consider, doubt. Make the assessment as specific as
possible; however, if it is not at all clear then use the symptom or sign as your assessment.
Example: Chest pain
R/O angina pectoris

Plan: This is what you, the patient, and the preceptor plan to do for each problem in the
assessment. The plan includes: plans for diagnostic tests, treatment including prescription and
non-prescription drugs, non-drug therapy, including dosages and frequencies, patient
education regarding diagnosis, complications of disease and/or drugs, lab tests, patient
behavior, safety etc., follow-up which includes next appointments, when you will call the
patient back with results of tests, why to come back sooner than appointed, step-wise plans if
appropriate for future visits, etc.

The follow-up instructions are usually the last entry in the plan.

Print and sign your name, followed by PA-student.

28
 SAMPLE SOAP NOTE
3/20/15 6:00 pm
Patient: C.S., 36 yo ♂ MR# 62545
Source: self, seems reliable

CC: Chest pain x 3 weeks

S: 36 yo male with no PMHX presents c/o chest pain x 3 weeks. Pt states that he had a gradual
onset of intermittent, non-radiating left-sided chest pain X 3 weeks. He does not recall what he
was doing when the pain first started. It is described as “sharp, sticking” and “very strong” ,
7/10 pain. Sometimes it is so “strong” that he bends forward with the pain. Has experienced the
pain when he is sitting, as well as with exertion or movement, including combing his hair this
morning. The pain has lasted for as little as 5 minutes and as long as 4-5 hours on different
occasions. No pain at this time. He does not recall ever having pain like this before. He has
taken Tylenol for the pain with some relief, but the pain comes back. It seems to be worse in the
evening. Pain is not getting more severe but concerns the patient. Worried he may have heart
disease.
Denies SOB, palpitations, fever, diaphoresis, N/V, cough, wheezing, night sweats, recent
weight loss, calf pain, leg swelling, dizziness or syncope. Denies history of a heart murmur,
rheumatic fever, any heart disease, HTN. Never had a CXR or ECG.

PMH:
Adult Illness: Denies
Surgeries/Hospitalizations: Denies
Current Meds: Tylenol 500 mg 1-2 tabs po prn for the pain – takes approx 3/day.
Allergies: Amoxicillin – hives, NKFA, NKEA
FH: Denies FH of CAD, MI
SH: History of smoking ½ ppd x 15 years, quit 2011. Drinks 2-3 beers on the weekend.
Denies use of cocaine, amphetamines, marijuana or other recreational drugs. Single. Sits at a
desk all day. Recently joined a gym. Works out at gym 2-3 nights/wk doing weights and
Stairmaster.

O: BP = 134/84 right arm sitting, P=72, regular, RR=16 unlabored, T=98.6F oral
Gen: Pt. in NAD, cooperative, resting comfortably in bed.
Neck: No accessory muscle use. No JVD. No carotid bruits. Carotid pulses 2+ b/l.

29
Chest: No ecchymosis, deformity, signs of distress. Reproducible point tenderness to left 3 rd
intercostal space MCL. Resonant throughout. Breath sounds vesicular, symmetrical, without
wheezes, rhonchi or crackles B/L
Cardiac: No lifts, heaves or visible pulsations. No thrills. PMI 5th ICS, MCL. Clear S1 & S2
without murmur, gallop or rub. Neck veins nondistended at 300.
Abd: Normoactive BS X 4. No bruits. Soft, nontender, no masses or organomegaly palpated.
Pulses: Femoral, PT and DP 2+ and equal bilaterally
Extremities: No edema of feet and ankles. No C/C/E (clubbing/cyanosis/edema.) No
varicosities. No discoloration, pigmentation changes, ulcers or lesions. Hair present on toes.
No calf tenderness, negative Homan’s.

EKG: Normal sinus rhythm, no acute changes, rate 72bpm

CXR: No infiltrates bilaterally, no cardiomegaly, no masses

A&P: Probable costochondritis

Naprosyn 500mg 1 tab po q 12 h with food. Ice alternating with heat to chest. Avoid
aggravating movements, no gym x 3 weeks. Patient understood and agreed with the following
patient education. Patient educated on the probable diagnosis. Discussed the side effects of
medications prescribed including risk of GI and renal disease. Educated on the importance of
taking medications with food. Go immediately to ED or call 911 for worsening of condition
especially if SOB, nausea, vomiting or diaphoresis. RTO 1 week for follow up.

Name and Signatures, PA-S

SAMPLE PEDIATRIC SOAP NOTE

12-1-2014, 12:25 PM
Patient: J.T. 14 month old ♂
Source: self and mother, reliable

CC: “My baby has been pulling at his ears x two days.”

This is a 14-month-old male who presents to the clinic for the first time with his mother who
states the child has been irritable and pulling at both his ears for the last two days. The child has
had a “cold” for the last five days, with nonproductive cough and rhinorrhea. His appetite has

30
decreased over the last 24 hours. Episode of left otitis media at 9 months of age, treated with
amoxicillin for 10 days, older sister at home is getting over a cold.
Denies fever, lethargy, diaphoresis, rash, vomiting and diarrhea.

Prenatal History: Received regular prenatal care, no complications, gained 30 lbs.

Birth History: 6-lbs. 12 oz 20”, NSVD at 40 weeks gestation at LHH, no complications.
Stayed 2 days. Apgar 10 and 10.
Dietary History: Breast fed x 3 months, then Enfamil with Iron; now on whole milk, juice,
cereal fruits and vegetables - all well tolerated.
G & D: smiled at 1 month, rolled over at 4 months, sat without support at 6 months, walked at
11 months, knows “mama”, “dada”, “baba”, “barney” and a few other words.
Immunizations: up to date as per mom, no adverse reactions reported.
Mother states she will bring in immunization card at next visit
Medications: Denies taking any medications. Takes 1 dropper of MVT daily.
Medical History: Denies history of congenital anomalies, anemia, asthma, diabetes mellitus,
heart disease or murmur, renal disease or pneumonia.
Surgical History: Denies surgery.
Hospitalizations: Denies.
Allergies: Denies food, medication or environmental allergies.
Family History: MGM has HTN.
Denies family history of asthma, tuberculosis, heart disorders, seizures, renal disease,
gastrointestinal disease, psychiatric disorders, anemia, diabetes mellitus, hyperlipidemia,
genetic disorders, HIV, musculoskeletal disease, neuromuscular disease and cancer.
Social History: Lives in a well heated apartment building with mother, father and sister age 5.
They rent a two-bedroom apartment. Siblings share a bedroom. Father smokes outside. No
pets. No daycare. Mother is a housewife, father is a mechanic.

Vitals: T 101.2F rectal P 100 reg. R 36/min/unlabored Ht 30”Wt 28 lbs HC 46 cm

Gen. App.: Alert and irritable male in no apparent respiratory distress; non-cooperative during
exam. Consolable.
Skin: warm, no pallor or cyanosis, no eczema or rashes noted.
Head: NC/AT, anterior fontanel open and flat, posterior fontanel closed.
Eyes: pupils--positive red light reflex bilaterally, conjunctiva pink, moist and non-injected
bilaterally. Crying with tears. No discharge noted.
Ears: The external ears showed no deformities. External canals with cerumen bilaterally. The
TMs were dull and erythematous bilaterally (R>L), no perforation noted.

31
Nose: Nose is normal in shape and size with crusted secretions around both nares. Septum was
midline, positive clear nasal discharge noted. No nasal flaring.
Throat: Tongue well papillated and pharynx clear. Uvula midline. Buccal mucosa pink and
moist, no lesions. Tonsils without edema, erythema or exudates.
Neck: Neck supple, full active/passive ROM. No masses or lymphadenopathy.
Lungs: No retractions . The thorax was symmetrical with symmetrical expansion. Lungs clear
to auscultation bilaterally, no wheezes, rhonchi or crackles.
Cardiac: No abnormal pulsations. PMI in the left 5th ICS MCL. Clear S1 S2 without murmur,
gallop or rub.
Abd: Non-distended. No scars. Bowel sounds present. Non-tender, no masses or
organomegaly.
Genitalia: Normal male genitalia, uncircumcised, foreskin retracts easily. Normal meatus.
Testes descended bilaterally. No hydrocele or hernias.
Ext.: Good femoral pulses bilaterally. Moving all extremities well.
Neuro: Walks freely. Grasps object and transfers hands.

Assessment: 1. B/L AOM (R>L)

2. URI
Plan: Amoxil suspension 125mg/5 ml 1 tsp TID x 10 days
Tylenol elixir 160mg/5 ml 1 tsp q 4-6 hours prn pain or fever >101
Increase fluid intake
Patient’s parents understood and agree with the following patient education. Educated on the
probable diagnosis, side effects of medications and their administration, and purpose for
increased fluid intake. Parent instructed to return to the office in 48 hours if symptoms persist
or immediately if symptoms worsen especially if fever >102 F rectally, inconsolable, vomiting.
Re check 10 days

Sign and Print Name

SAMPLE INPATIENT PROGRESS NOTE

1/6/11 at 7:00 am
Patient: L.R. 50 yo Male MR # 000-111-222

CC: “I’m doing well”

32
S: 50 yo M admitted to LHH 1/5/07 for cholelithiasis with cholecystitis whom is presently
without complaints. On admission, US with thickened GB wall at 6mm, multiple stones,
pericholecystic fluid. Rx with D5 ½ NS @ 125 cc/hr, Metronidazole 500 mg IV q8h,
Cefuroxime 750 mg IV q8h, Reglan 10 mg IV q3h prn, Demerol 50 mg IM q4h prn pain. For
cholecystectomy today at 12 pm. Pt presently NPO.
Denies fever, chills, weakness, n/v/d

O: BP:130/80 right arm lying, Pulse: 84 regular, RR: 16 unlabored, T: 99.0 º F oral
General: WN/WD in NAD. Resting comfortably in bed.
Skin: no jaundice, rashes or lesions
Eyes: nonicteric
Lungs: CTA b/l . No rales, rhonchi or wheezing
Cardiac: S1, S2 audible. Grade 2 systolic murmur with midsystolic click. No gallops or rubs.
No JVD
Abd: no scars or lesions noted, +BS, soft, mild RUQ tenderness. + murphy’s. No rebound or
guarding.

EKG: NSR at 75 bpm CXR: no infiltrate

Labs:
Amylase: 90 UA: negative
Lipase: 100 Urine Culture: pending
AST: 18 Repeat K: 4.5
ALT: 16 Last BGM 5:30 am: 160
Alk Phos: 80
Total Bili: 0.7

A: 1) Cholecystitis
2) DM Type 1: last BGM: 160
P: 1) For cholecystectomy at 9am today.
-continue Metronidazole, Cefuroxime, Demerol and Reglan
2) Continue BGM before meals and insulin coverage on sliding scale
3) Pt medically cleared for OR, Consent in chart
4) Pt seen by Social Services, to arrange for HHA on discharge, consult on chart.
5) Pt Ed: Pt aware will be going to OR 9am today. Understands need, risks, benefits
associated with surgery. Pt verbalizes understanding of the above information.

Print and Sign, PA-Student

33
 BEHAVIORAL MEDICINE NOTE TEMPLATE

Patient Identifying Data: Date:

Source of Info:
CC/Reason for encounter:
HPI
Elements: Location, Quality, Severity, Duration, Timing, Content, Modifying Factors,
Associated Signs & Symptoms
Past psych history:
Past medical history:
Medications:
Surgeries:
Allergies:
Past family and social history(PFSH):
ROS & Active medical problems

Psych Exam
Vital Signs:
Blood Pressure, __Temp__Pulse __ Respiration __Height___ Weight _____
General Appearance and Manner: (e.g., development, nutrition, body habitus, deformities,
attention to grooming)
Musculoskeletal: Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic)
(note any atrophy or abnormal movements) (and/or) Examination of gait and station
Speech: ___rate__volume__articulation__coherence__spontaneity (note abnormalities; e.g.,
perseveration, paucity of language)
Thought processes: __associations__processes__abstraction __computation
• Description of associations (e.g., loose, tangential, circumstantial, intact):
• Description of abnormal or psychotic thoughts (e.g., hallucinations, delusions,
preoccupation with violence, homicidal or suicidal ideation, obsessions):
Suicidal ideation: __ Present__ Absent Homicidal ideation: __Present __ Absent
Violent ideation: __Present __ Absent
• Description of patient’s judgment and insight:
• Orientation:
• Memory (Recent/Remote):
• Attention/Concentration:
• Language:
• Fund of knowledge: __intact __inadequate
34
 • Mood and affect:
Other Findings (e.g. cognitive screens, etc.):

Signature

SAMPLE BEHAVIORAL MEDICINE NOTE

Pt ID: MR# 12345678910

Source: self
2/13/13

CC- “I want to kill myself” x 2 months

37 yo homeless, unemployed male with history of depression and alcohol dependence is c/o “I
want to kill myself” x 2 months. States his depression and suicidal ideation are becoming
worse because if is feeling hopeless about his current situation of being homeless and
unemployed. He now reports having a clear plan for killing himself. Pt states he is “giving
up”. When asked he states he plans on taking a bottle of pills to end his life. Pt reports recent
hospitalization at Bellevue Hospital for suicide attempt 1 week ago. Prior to that hospitalization
he took a bottle of Prozac. Currently he reports feeling worthless and helpless. Associated
symptoms include difficulty sleeping, decreased appetite and anxiety. Anxiety is worse in the
morning and causing him to start drinking alcohol in the mornings. He drinks 1-2 pints of
vodka daily for the past 4 months. Last drink was >48 hours ago (prior to admission to
Bellevue). Pt has been homeless since losing his job in 2012 and does not like living in a
shelter. He has no social support and is estranged from his family. His mother (who he thinks
had undiagnosed depression) committed suicide at 54 years old (when he was 24 years old) and
his maternal grandfather committed suicide at age unknown (before he was born). When asked
about illicit drug use, states "I've sniffed heroin and smoked crack a few times, but I haven’t
done that in years.” Patient is medically cleared by adult emergency department. Denies history
of seizures, cutting or other forms of self-injury, homicidal ideations, hallucinations, manic
symptoms, h/o violence or criminal record.

Collateral Information: As per Bellevue Hospital: Pt has a history of ETOH

abuse, polysubstance abuse, and assault. Pt BIB police to Bellevue ED on 4/21/2015 for public
intoxication and altercation with another man about a bike; pt was positive for ETOH
(BAL=179) and benzodiazepines. During this visit pt expressed suicidal and homicidal ideation,

35
but retracted it the next morning and was discharged. He was referred to Bellevue MICA clinic,
but never went. As per Bellevue, pt has never had a previous psychiatric hospitalization for
overdose, although he has been seen in the ED intoxicated on multiple occasions c/o suicidal
ideation and suicidal attempt and then retracting the next morning.
Medical History: Denies history of DM, HTN, HLD, CAD, MI, or cancer.
Allergies: NKDA, NKFA, NKEA
Current Medications: denies
Social history: See HPI. Pt was born in Massachusetts and moved to Long Island at 15 years
old to take care of father with ALS. His parents divorced when he was 10 years old and his
father died of ALS when he was 15 years. Pt is a high school graduate and worked at the
Dakota building as a handy man for 7 years; since pt lost his job in 2006 he has worked handy
man jobs off and on.
Family history: See HPI

V/S: T: 98.9 degrees F, oral P: 94, regular rate and rhythm

BP: 134/84, RA sitting RR: 18 unlabored Pulse Ox: 97% RA
Mental Status Exam:
Appearance, attitude and behavior: Patient is a Caucasian male, appears stated age, dressed
in hospital gown sitting on stretcher. Appears mildly disheveled, hair uncombed, no scars,
tattoos or excessive piercing. Appeared anxious with some tapping of fingers and frequent
shifting of position throughout interview. Patient was cooperative and well-related with normal
eye contact. Normal gait, no tremor.
Speech: normal rate, rhythm, tone, and pitch. Good articulation and fluent; not pressured and
no accent.
Mood: Depressed. Patient said, "I feel hopeless."
Affect: affect is congruent to mood, labile (tearful at times throughout interview), full and
appropriate
Thought Process: linear and goal-directed, spontaneous and coherent
Thought content: significant for suicidal ideation with reported plan and intent, denies
delusions, homicidal ideation, or paranoid ideation
Perception: denies visual or auditory hallucinations, not internally preoccupied or responding
to internal stimuli
Cognition: awake and alert, oriented to person, place, time and circumstance, memory recall,
attention, and concentration grossly intact. No deficits in language or visual-motor integrity.
Insight/Judgment: impaired insight and judgment, continued to endorse active suicidal intent.
Patient does not have the ability to make appropriate decisions.

36
Labs:
Serum alcohol level < 10, Urinalysis: WNL, Toxicology: all negative
Assessment and Plan: 37 year old homeless, unemployed, single, Caucasian male with self-
reported history of depression x 22 years, alcohol dependence x 6 years, and 1 self-reported
previous psychiatric hospitalization due to suicide attempt by overdose (reports he took an
entire bottle of Prozac given to him by a friend) was brought in by self to ED endorsing
worsening depression and suicidal ideation with plan. Pt endorses suicidal ideation with plan
and intent and reports family history of 2 suicides. Pt presents with chronic depressive
symptoms. Pt is clinically sober (BAL < 10) and expressing strong desire for detox. Pt has
multiple stressors including homelessness, unemployment, and lack of social support. Given the
above assessment, pt is at a chronically elevated risk to harm self, and would benefit from
inpatient psychiatric hospitalization and detox.
Pt medically cleared by adult ED.
 Suicidal ideation with plan
o Voluntary psychiatric admission to psychiatric/detox unit (possibly Lutheran hospital
o Social Work currently looking for bed)
o Labs: CBC, LFTs
o EKG
o Pt requires one to one monitoring while in house given current suicidal ideation with
plan.
 Depression
o Pt will require outpatient follow up with Psychiatrist for evaluation, diagnosis and
management of depression
o May consider starting SSRI pending psychiatric evaluation during hospitalization
 Alcohol dependence
o Repeat CIWA exam monitor patient for signs of alcohol withdrawal, although
unlikely given current BAL < 10 and current CIWA of 4.
o Ativan 1 mg PO prn for moderate-severe anxiety
o Social work consult for help with social resources and counseling for alcohol
dependence and for help with housing and unemployment

Patient understands and agrees with plan. Will plan for inpatient psychiatry/detox admission
pending social work placement. Pt understands that NYU hospital dose not have a unit for detox
patients and that he will require transfer to another hospital for in patient hospitalization.

Signature

37
 Sample Surgical Notes

Pre-Op Note
Date
Time
Pre-Op Diagnosis:
Planned Procedure and Scheduled Time:
Indication:
Labs/studies:
---/---/--- { } --- { U/A LFT's
Official CXR reading: (on chart)
Official EKG reading: (on chart)
Type and Cross/Screen for __ units in blood bank
NPO after midnight
IVF ordered after midnight
Antibiotics ordered (1dose prior to OR/STAT)
Anesthesia evaluation (on chart)
Operative Consent (on chart)

Operative Note
Date
Time
Pre-Op Diagnosis: gallstone pancreatitis
Post-Op Diagnosis: same
Procedure: Laparoscopic cholecystectomy with Intraoperative cholangiogram
Surgeon: Lin
Assistants: Resident, MS
Anesthesia: GETA (General Endotracheal Anesthesia)
EBL: minimal
UOP (urine output): unmonitored (no Foley) or amount
IVF: 2000 cc crystalloid
Findings: Intraabdominal adhesions, distended GB, +GS, cholangiogram: mildly dilated CBD,
no filling defects, normal intrahepatic radicles, uninterrupted flow into duodenum
Specimens: GB to pathology
Drains: None
Complications: None
Disposition: To Recovery Room, extubated, in stable condition

38
Surgery Progress Note
Date
Time
POD#__ after __________________ Abx day #___
24hr events/subjective complaints
(Include presence or absence of nausea, vomiting, flatus, BM, ambulation, pain, chest pain,
SOB, and other PERTINENT info.)
Vitals: Tmax, Tcurrent BP, HR, RR, Pox (if available)
I/O: Total In/Total Out
8hr shifts - Ins broken down into IVF, PO, NGT, feeding tube, etc.
8hr shifts - Outs broken down into NGT, U/O, stool, emesis, drains, etc.
PE: Lungs – CTA bilaterally
Heart – RRR, no M/R/G
Abdomen –normoactive BS, soft, ND/NT
Wound – well-approximated, no erythema or d/c
Ext – no edema, calf tenderness, Homan’s negative
Labs (do not present orally if previously presented on rounds)
A/P: __ year old man/woman POD#___ after _____________progressing well
Neuro: Pain control adequate, continue PCA
OOB, ambulate today
CV: Mild tachycardia, will bolus with 500cc isotonic crystalloid and reevaluate
Resp: No issues, continue spirometry
GI: Await return of bowel function, continue NPO, NGT
GU: U/O ___cc by Foley, continue to monitor closely after volume load
Replete electrolytes
Heme: HCT 27 and stable, continue SQ Heparin 7500units q12hr
ID: Perioperative abx D/C'd, afebrile, check WBC today
Endocrine: Continue ISS, BS well controlled
Signature

Surgery ICU Progress Note

Date
Time
Significant 24hr events, subjective complaints (Ask the nurses!)
Meds
39
Neuro: PE, GCS, sedative drips, pain control CV: PE/vasc exam (where appropriate)
HR (range) BP (range) CVP (range)
Cardiac parameters (if PA cath in place)
CO CVP
CI PCWP
PAS/PAD SVR
SV
Resp: PE
RR (range) Pox ___% on RA/___%FIO2
Vent settings: mode, rate, TV, FIO2, PS, PEEP
ABG: pH/pCO2/pO2/TCO2/BE or BD/sat on latest vent settings
GI: PE incl wound, diet/tube feeds, drains/NGT output, LFT's
Renal/FEN: 24hr I/O's including breakdown into component parts
IVF rate
UOP/hr (in cc/kg/hr)
Labs: ---/---/--- {Ca, Mg, PO4
Heme/ID: Tmax, Tcurrent Abx day#___
} --- { INR/ PT/PTT Cx results:
Endocrine: Accuchecks, Insulin dosing, TFT's, steroids
A/P: ICU Day#___, POD#___after____________________
Neuro:
CV:
Resp:
GI:
Renal/FEN:
Heme/ID:
Endocrine:

40
 Sample OB/GYN Notes

Sample Labor and Delivery Admission Note

Date: 6/30/xx, 1300H
A.H., 36 yo female, MR #3616749
Source: patient
Reliability: pt appears reliable
Chief complaint: “I think I am in labor.”
HPI: 36 yo G2P0010 EDC 7/12/xx based on LMP of 10/5/xx at 38 wk 2 days c/o painful
contractions since 0500H today. Pt states contractions were initially mild, occurring about every
20 minutes, but that they are now more severe and occur every 7 minutes. She currently rates
the pain as an 8 on a scale from 1-10. Pt admits to good fetal movement today. She has had
mild vaginal spotting since this morning. She denies any h/o: leakage of fluid per vagina. Pt
states she last ate and drank at 0800H, when she had scrambled eggs and orange juice. Pt
requests epidural analgesia.
Prenatal care: Dr Kaiser, private practice, 14 visits, no complications to date
Labs: GBS negative, A positive, antibody negative, HIV nonreactive, HBsAg negative, RPR
nonreactive, rubella non-immune
Past obstetrical history: 4/2012 Uncomplicated medical voluntary termination of pregnancy at 8
weeks
Past gynecologic history: denies hx of: STIs, myomas
Past medical history: positive for mild asthma. Has used steroids once due to exacerbation after
contracting influenza. Denies hx of: intubation or admission.
Past surgical history: status post tonsillectomy and adenoidectomy at age 6
Medications: prenatal vitamins; albuterol as needed
Allergies: no known drug allergies; no known food allergies
Social history: denies h/o toxic habits. Denies hx of domestic violence.
Review of systems: positive for painful contractions, constipation, and vaginal bleeding. Denies
hx of: nausea, vomiting, diarrhea, dysuria.
Vital signs: HR 68/min BP 102/72 mm Hg temp 36.7o C
General: pleasant gravida in acute painful distress
Chest Clear to auscultation, equal breath sounds bilaterally
Cor: regular rate and rhythm, S1S2, II/VI systolic ejection murmur heard best at the left sternal
border, no rubs or gallops noted
Abd: +normoactive bowel sounds, soft, gravid, non-tender. Fundal height: 37 cm. Cephalic
presentation by Leopold’s maneuvers. Estimated fetal weight: 3400 gm by Leopold’s
maneuvers.
41
Sterile speculum exam: deferred
Sterile vaginal exam: 5 cm/80% effaced/-2 station, vertex presentation
Extremities: no cords, cyanosis, or edema. No calf tenderness.
Data
EFM: baseline=145 bpm, Category 1 tracing, moderate variability, + accelerations, no
decelerations
Tocodynamometry: contractions q2-3 min
Bedside ultrasound: vertex presentation, anterior placenta, subjectively normal amniotic fluid
volume
Lab data (date of admission):
CBC: 5.7>11.6/34.8<187
Type and screen received by blood bank
Ultrasound report #1 (11/22/xx) (6 wk, 6 days GA) : CRL=7.7 mm, corresponding to 6 wk, 6
days GA
Ultrasound report #2 (2/20/xx) (20 wk GA): anatomy scan reveals no anomalies. Anterior
placenta. Transverse lie, back down. Subjectively nl amniotic fluid.
Ultrasound report #34 (6/16/xx) (36 wk, 2 days GA): Anterior placenta. Vertex presentation.
Amniotic fluid index: 14.5 cm. Estimated fetal weight: 2700 gm.
Assessment:
1. 36 yo G2P0010 EDC 7/12/xx at 38.2 wk EGA in latent phase labor. 2. Advanced maternal
age. 3. Rubella non-immune status. 4. Desirous of epidural analgesia.
Plan:
1. Admit to Labor and Delivery. 2. Clear liquid diet. 3. Continuous fetal monitoring and
tocodynamometry. 4. Dextrose 5% in lactated Ringer’s solution IV at 125 cc/hr. 5. Anesthesia
consult for epidural analgesia. 6. Dr Kaiser notified.

Sample Delivery Note

Date and time:
Summary: NSVD of a live male, 3000 gm and Apgars 9/9. Delivered LOA, no nuchal cord,
light meconium.
Nose and mouth bulb suctioned at perineum; body delivered without difficulty. Cord clamped
and cut. Baby handed to nurse. Placenta delivered spontaneously, intact. Fundus firm, minimal
bleeding. Placenta appears intact with 3 vessel cord. Perineum and vagina inspected – small 2nd
degree perineal laceration repaired under local anesthesia with 2-0 and 3-0 chromic suture in the
usual fashion. EBL 350cc. Hemostasis. Pt tolerated procedure well, recovering in LDR. Infant
to WBN.
42
Sample Operation Note
Date and Time:
Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at term, failure to progress`
Postop Diagnosis: Same
Procedure: TAH/BSO or Cesarean Section
Surgeon (Attending):
Anesthesia: GET (general endotracheal, others include spinal, LMA, IV sedation)
Complications: None
EBL: 300 cc
Urine Output: 200 cc, clear at the end of procedure
Fluids: 2,500 cc crystalloid (include blood or blood products here)
Findings: Exam under anesthesia (EUA) and operative
Specimen: Cervix/uterus
Drains: If placed
Disposition: Recovery room, Surgical ICU, etc

Sample Postpartum Notes (Soap format)

Date and Time:
Ask every patient about:
• Breastfeeding – are they breastfeeding/planning to? How is it going? Baby able to latch on?
• Contraceptive plan with relevant sexual history
• Lochia (vaginal bleeding) – Clots? How many pads?
• Pain – cramps/perineal pain/leg pain? Relief with medication? Do they need more pain meds?
• Vital signs
• Focused physical exam including:
Heart
Lungs
Breasts: engorged? Nipples – skin intact?
Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
Perineum: Assess lochia (blood on pad, how old is pad?)
Visually inspect perineum – Hematoma? Edema? Sutures intact?
Extremities: Edema? Cords? Tender?
• Postpartum labs: Hemoglobin or hematocrit
Assessment/Plan: PPD#___ S/P NSVD or Vacuum or Forceps (with 4th-degree laceration, with
pre-eclampsia s/p Magnesium Sulfate)
• General assessment – Afebrile, doing well, tolerating diet
43
• Contraception plans (must discuss before patient goes home)
• Vaccines – does pt need rubella vaccine prior to discharge?
• Breastfeeding? Problems? Encourage.
• Rhogam, if Rh-negative
• Discharge and follow-up plan
• Patients usually go home if uncomplicated 24-48 hours postpartum
• Follow-up appointment scheduled in 2-6 weeks postpartum

Sample Postoperative Cesarean Section Orders/Note

Sample C/S Orders
Admit to Recovery Room, then postpartum floor
Diagnosis: Status post (s/p) C/S for failure to progress (FTP)
Condition: Stable
Vitals: Routine, q shift
Allergies: None
Activity: Ambulate with assistance this PM, then up ad lib
Nursing: Strict input and output (I&O), Foley to catheter drainage, call MD for Temp > 38.4,
pulse > 110, BP < 90/60 or > 140/90, encourage breastfeeding, pad count, dressing checks, and
Ted’s leg stockings until ambulating
Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids
IV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters
Labs: CBC in AM
Medications:
• Morphine sulfate PCA (patient controlled analgesia) per
protocol (1 mg per dose with 10 minute lockout, not to exceed 20 mg/4 hours)
• Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well
• Vistaril 25 mg IM or PO q 6 hours prn nausea
• Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well
• Prophylactic antibiotics if indicated
• Thromboprohylaxis for high-risk patients
• Rhogam, if Rh-negative

Sample Post C-Section Note

Date and Time:
Day #1 (Post-op day POD#1)
Subjective: Ask patient about:
• Pain – relieved with medication?
44
• Nausea/vomiting
• Passing flatus (rare this early post-op)
Objective:
• Vital signs and note tachycardia, elevated or low BP, maximum and current temperature
• Input and output
• Focused physical exam including:
Heart
Lungs
Breasts: engorged? Nipples – Is skin intact?
Incision: Clean and dry, intact?
Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
Perineum: Assess lochia (blood on pad, how old is pad?)
Visually inspect perineum – Hematoma? Edema? Sutures intact?
Extremities: Edema? Cords? Tender?
• Postpartum labs: Hemoglobin or hematocrit
Assessment/Plan: POD#1 status post (S/P) C/S or repeat C/S (indication for the C/S)
• Afebrile, tolerating pain with medication, oral intake, adequate urine output
(>30cc/hr)
• Routine post-op care
Discharge Foley
Discharge PCA or IV pain medications and PO pain Meds when tolerating PO
Out of bed (OOB)
Advance diet as tolerated
Discharge IV when tolerating PO
• Check hematocrit or CBC

Sample Gynecologic History and Physical

Introduction: Name, age, gravidity, parity and presenting problem
HPI:
Past Medical History/Past Surgical History:
Past Gynecologic History:
• Menses – menarche, cycle duration, length, heaviness, intermenstrual bleeding, dysmenorrhea,
and menopause (if relevant).
• Abnormal Pap smears, including time of last Pap
• Sexually transmitted infections
• Sexual history

45
• Postmenopausal women. Ask about hypoestrogenic symptoms, such as hot flashes or night
sweats, vaginal dryness, and about current and past use of hormone/estrogen replacement
therapy.
• Mammogram
Past OB History: Date of delivery, gestational age, type of delivery, sex, birthweight and any
complications
Family History:
Allergies:
Medications:
Social History:
Physical Exam: Complete
Review of Systems:
Plan:
1. Pap smear
2. Endometrial biopsy obtained
3. Medications, etc.

Gyn Clinic SOAP Note

July 28, 2015 1050 AM
Patient: LR, 27 yo F, MR # 12345
Source: Self, seems reliable

CC: “I have smelly discharge” x 3 weeks

The patient is a 27 yo F, G1P0010, LMP 6/19/15, with IUD and no other PMH, presenting to
GYN clinic, complaining of malodorous vaginal discharge x 3 weeks. Patient states the
discharge is clear, smells “like a dead rat,” came on gradually, is worse after sexual intercourse,
and is similar in quantity to her normal discharge. Patient states that she has been drinking lots
of water, completed an OTC course of Monistat cream 1 week ago, and has been washing her
vagina with water and vinegar x 2 weeks, all without symptom improvement. Patient states she
is embarrassed of the discharge smell and needs treatment. Patient denies fever, chills,
abdominal pain, constipation, diarrhea, dysuria, hematuria, changes in urine color, UTI
symptoms, history of STDs or vaginal infections, vaginal lesions, rash, pruritus, pelvic pain,
abnormal menstruation. Last PAP and GC/Chlamydia culture negative on 3/23/15. Sexually
active with 1 partner of 4 years who has no symptoms. States uses condoms every time she is
sexual active and had IUD placed in 2014.
Medications: None
Allergies: NKDA, NKFA, NKEA
46
PMH: Denies DM, HTN, asthma, abdominal complaints.
OBGYN: Currently in heterosexual, monogamous, sexually-active relationship, with good
libido and ability to enjoy relations. Denies history of STDs, UTIs and vaginal infections.
Patient uses condoms and IUD (placed February 2014). 15 yo at menarche, with regular
menstruation every 28 days, lasting 5 days, with mild blood loss.
Hospitalizations/surgeries: Dilation and curettage for unwanted pregnancy, February 2014,
unknown physician, NCB, no complications.
FH: Non-contributory
Social history: Patient denies alcohol, tobacco or illicit substance use.
VS: BP: 117/75 L arm sitting, HR: 75, regular, RR: 18, unlabored, T: 98.1 F PO, O2: 99% RA
General: Patient is sitting on exam table in no acute distress. Patient is cooperative, well
nourished and developed, with good grooming and hygiene.
Skin: No rashes or lesions. Warm and dry, with color WNL.
Cardio: Rate and rhythm regular, S1 and S2 clear. No murmurs, gallops or rubs.
Lungs: No deformity or tenderness. CTAB, without rales, wheezes or rhonchi.
Abd: Non-distended. No scars or lesions. BSx4 normoactive. No bruits. Soft, nontender, no
HSM, or CVA tenderness.
Rectal: No external hemorrhoids or lesions. Good anal sphincter tone with trace, soft, brown
stool in vault. FOB negative.
Genital: Note: Chaperone present during examination
 External: No rashes, lesions, erythema, masses or swelling.
 Vaginal: Normal rugae, vaginal mucosa moist. Thin, gray, copious vaginal discharge in
vault. No blood in vault. Cervix: Closed with IUD string visualized and thin, gray vaginal
discharge. No lesions or CMT.
 Bimanual - Uterus- Anteverted. Non-tender. Size, shape and consistency WNL. Adnexa-
Non-palpable and non-tender.
A&P: Patient is a 27 yo F, G1P0010, LMP 6/19/15, with IUD, presenting with thin, clear/gray,
malodorous vaginal discharge x 3 weeks. Patient with probable bacterial vaginosis.
1. Probable bacterial vaginosis. Possible candidiasis vs. trichomoniasis. R/O gonorrhea,
chlamydia and pregnancy. Consider UTI.
 Wet mount
 KOH
 Culture for GC/Chlamydia
 Urine hCG
 Flagyl 500mg PO BID x 7 days
2. HCM
 Return to GYN clinic for yearly examinations
47
  Discuss safe sex practices and self breast examinations
 Follow up with PMD for yearly examinations
Patient educated on probable diagnosis and other differential diagnoses. Patient understands the
need for testing to arrive at a more conclusive diagnosis. Patient understands that the results of
some tests will be immediately available during this visit, and that she will be notified by
telephone as other results become available. Patient understands the need for antibiotics and to
notify her partner, so that he may be tested and treated as well. Discussed side effects of
medication and not to drink alcohol while taking it. Patient should return to GYN clinic or ED
if symptoms worsen, or if new symptoms appear, such as pruritus or dysuria. Patient verbalizes
understanding and agrees with plan. All questions were answered to the patient’s satisfaction.
Follow up in office in 1 week or go to ED sooner if symptoms worsen.

Signature

OB Notes- Prenatal:
L.M., 28 y/o female, MR#XXXXX
06/22/15, 10:00 AM, Outpatient Clinic
Source: Self, seems reliable.

CC: 24 week prenatal visit

HPI: 28 y/o G1PO Rh+ female with no significant PMHx presents to the outpatient clinic for
her 24 week visit. Pt reports she is feeling well and has no complaints at this time. Pt states she
feels the baby move often. Pt denies recent injury/trauma, recent fall, recent travel or sick
contact, syncope, dizziness, headache, fever, chest pain, palpitations, SOB, abdominal pain,
NVD, constipation, vaginal bleeding or discharge, dysuria, bloody stools, limited ROM, neck or
back pain, or swelling of ankles/feet.

PMHx: Denies.
PSHx: Denies.
Family History: Denies family h/o DM, HTN, HLD, CAD, or cancer.
Allergies: NKDA. NKFA. NKEA.
Meds: Citranatal PO 1 tab daily
Social History: 28 y/o Hispanic female residing with her husband in a single family home in
New Rochelle, New York. Pt works as a secretary in a local doctors office. Pt’s highest level of
education is high school. Pt eats 3 meals per day consisting mainly of bread, rice, fish, chicken,
48
and vegetables. Pt runs or uses an elliptical for about 45 minutes/day 4 days a week for
exercise. Denies cigarette smoking, alcohol consumption, or illicit drug use. Pt is in a
monogamous sexual relationship with her husband. Pt is not currently on birth control and does
not use condoms.

Physical Exam:
 Vital Signs: Temp: 98.6 F (PO), Blood Pressure: 110/70 mmHg right arm sitting, Pulse:
75 BPM, Respiratory Rate: 17 breaths/min unlabored, 02 sat 100% (Room Air), Height
5’0” inches, Weight 160 lbs
 General: WN/WD. AOx3 in no acute distress. Appears stated age. Speaking in complete
sentences, no accessory muscle use or retractions. Sitting comfortably on exam table.
 Skin: No rashes, lesions, ulcers, striae, or ecchymosis. No nail changes. Warm, dry, color
good. Good turgor.
 Neck: Supple. FROM. No spinal tenderness. No lymphadenopathy of pre/postauricular,
occipital, tonsillar, submandibular, submental, superficial/deep cervical or
supraclavicular nodes. Trachea midline. Thyroid smooth, not enlarged, non-tender.
 Thorax/Lungs: No deformity. Normal AP to Lateral Diameter. Symmetrical excursion
bilaterally. Chest wall non-tender to palpation. Percussion and tactile fremitus equal b/l.
Resonant throughout. Breath sounds vesicular and symmetrical. No rales, rhonchi or
wheezing appreciated B/L.
 Cardiovascular: No lifts, heaves, visible pulsations. No thrills. PMI 2 cm in Left 5th ICS.
Rate and rhythm regular, S1 & S2 clear. No murmur, gallop or rub appreciated. Neck
veins nondistended at 30o.
 Breast: Mildly tender to palpation b/l. Breasts symmetric. No lumps, bumps, puckering,
or nipple retractions noted b/l. Euthermic. No rashes, lesions, ulcers, discoloration, skin
breakdown, or ecchymosis noted b/l. No axillary or supraclavicular or infraclavicular
lymphadenopathy.
 Abdomen: Fundal height 25 cm. Non-distended. No scars, lesion or visible pulsations. No
caput medusae. Bowel sounds normoactive X 4. No bruits. Soft, nontender, no masses
palpated. No rebound tenderness or voluntary/involuntary guarding. No
hepatosplenomegaly to percussion/palpation. No CVA tenderness.

 Genitalia: No lesions, masses or swelling. No discharge, no blood in vault. Vaginal
mucosa moist. Cervix nulliparous, closed with no cervical motion tenderness. Uterus
enlarged appropriate for 25 weeks, firm and smooth. Adnexa non-tender without palpable
masses b/l. No inguinal lymphadenopathy b/l.

49
  Musculoskeletal: No deformities, wasting, atrophy, swelling. Normal color and
temperature. No bony or soft tissue tenderness. Full ROM without tenderness in hands,
wrists, elbows, shoulders, spine, hips, knees, ankles. Strength 5+/5+ bilaterally upper and
lower extremities. No scoliosis or excessive kyphosis/lordosis. NO calf tenderness or
swelling.

Fetal Heart Rate: 160 BPM

Assessment and Plan:

Intrauterine Pregnancy
 Urinalysis
 Glucose Challenge Test
 Ultrasound for fetal anatomy
 Continue Citranatal prenatal vitamins
 Follow up in 4 weeks at 28 weeks of gestation
 Patient Education
 Educate patient regarding oral glucose challenge test, as it is needed to rule out
gestational diabetes. Tell the patient that she will be instructed to drink a sweet liquid,
which will be provided for her, and an hour later her blood will be taken and the
glucose level will be measured. If the glucose level is below 140 mg/dL gestational
diabetes can be ruled out. If the glucose level is above 140 mg/dL the patient will need
to have the glucose tolerance test.
 Educate patient regarding the importance of compliance of Citranatal, her prenatal
vitamin, as it contains folic acid, which can prevent neural tube defects, and iron,
which can prevent anemia.
 Educate patient regarding screening tests needed at her 28 week visit (the next visit).
These tests include a CBC to test for anemia, RPR/VRDL to screen for syphilis, HIV
test, and urinalysis. Tell the patient that after her 28-week visit she is expected to
come back every 2 weeks until 36 weeks of gestation and weekly after that until she
delivers.
 Educate patient regarding the dangers of alcohol consumption, illicit drug use, and
cigarette smoking or exposure during pregnancy.
 Educate patient regarding signs or symptoms of labor such as contractions that occur
at frequent regular intervals and premature rupture of membranes or “breaking your
water.” Tell the patient if any of these events should happen she should go straight to
the hospital.

50
Patient expresses verbal understanding and agrees to above interventions.

Signature

OB – ruptured membrane note

CC: “I think my water broke” x 6 hours
22yo female G1P0, currently 39w4d presents c/o “I think my water broke” x 6 hours. As per pt,
LMP 9/10/14, EDD by sono 6/17/15. States that fluid is a clear and a small amount that has
been continuous since onset. Denies brown/green fluid color. Also admits to lower abdominal
pain described as cramping contractions that began ~3hours ago. They are at regular intervals
q10-15 minutes. Pt receives regular prenatal care, last exam was yesterday. Pt reports normal
pregnancy course, no complications. Neg GBS, HIV negative, PPD negative, VDRL negative,
GC/Chlam negative. No GDM. Pt reports good fetal movement. Denies fever, chills, n/v/d,
CP, SOB, vaginal bleeding, dysuria.
PMH/hosp/surgeries – denies
Meds – prenatal vitamin daily
Allergies – NKDA, NKFA, NKEA
Family hx – denies DM, HTN, breast CA, ovarian CA, endometrial or cervical CA
Social – Married, lives with husband in apartment in the Bronx. Unemployed. Denies etoh,
smoking and illicit drug use.
Vitals: BP125/85RAS, P 80bpm, R 18, T98.0 oral
General – WN/WD, in NAD
Skin – no rashes
Lungs – CTA b/l
CV – regular rate and rhythm, no murmurs
GYN – Leopold maneuvers performed, head is appreciated in pelvis, Enlarged soft uterus
palpated below xiphoid process. No lesions, masses or swelling of external genitalia. Clear
fluid leaking from cervical os with pooling at posterior fornix. Cervix without lesions. Cervix
is soft, 2cm dilated, 50% effaced, -2 station. No odor.
Ext – no swelling, cyanosis or edema
Neuro – A&Ox3
Test – Ferning test +
A/P: ROM
 Admit to L&D
 Labs – CBC, T&S, UA, RPR
 Induce labor with Pitocin 2milliunits/min IV q30 min until contractions established
 monitor for signs of chorioamnionitis
51
  Vitals q 4 hours
 Continuous monitoring MHR and FHR
 Pt informed that membranes ruptures. Induction of labor discussed, pt agrees to receive
Pitocin. Side effects discussed - uterine rupture and tetany, HTN, NV. Pt understands
and agrees with plan.
 Pt will notify staff if pain worsens.

Signature

GYN Annual visit note

51 y/o G4P3013 here for annual exam. Hx of 3 NSVD and uterine fibroids. LMP 8/2006. Pt
had supracervical hysterectomy 8/2006. Mutually monogamous relationship with husband only.
No hx of STD. No current GYN complaints. No hx of abnormal Paps. Last PAP 11/2013. Last
mammo 6/2014, normal. + BSE. Up to date on all immunizations.
PMH/surgeries- see HPI
Medication – MVT daily
Allergies- NKDA, NKEA, NKFA
Fam hx- denies history of cervical, breast or ovarian cancer
Social hx- drinks 1 glass a wine daily, no cigarettes or illicit drug use
Vitals: BP 124/76 RAS, P 70bpm, RR 17 unlabored, T 98.3 oral, Ht 5’4” Wt 136lbs
General – WN/WD in NAD, sitting comfortably on exam table
Lung – CTA b/l, no wheezing/rales/rhonchi
CV – S1S2 audible, no M/G/R
Breast – no erythema, discoloration, dimpling, nipple inversion, discharge or retractions. No
masses or tenderness. No LAD.
Abd- +BS, soft, non-tender to palpation, no CVAT
Genital – external without lesions, masses or swelling. Canal with scant white discharge, no
blood in vault. No lesions. Mucosa pink and moist. Cervix visualized and without lesions. No
CMT or adnexal masses or tenderness.
A/P:
Annual exam
No abnormal findings. PAP done today, results pending. Will notify pt if the results were
abnormal. STD panel and HIV counseling and testing offered. Encouraged pt to continue SBE
monthly. RTC in 1 year for annual exam.

Signature
52
 Sample Procedure Notes

Suture Procedure Note

Patient was positioned appropriately, ___cc lidocaine with/without epinephrine was used as a
local anesthetic. 500cc NaCl was used for irrigation. Patient was sterile draped with wound
exposed. __x _.0 nylon (type) sutures were placed with good approximation. Wound dressed
with bacitracin and sterile gauze. Procedure tolerated without complications. N/V intact.

Incision & Drainage Procedure Note

Patient positioned appropriately, __cc lidocaine with/without epinephrine was used as a local
anesthetic. #11 blade scalpel used for single incision. Additional local anesthetic injected into
surrounding viable tissue prior to blunt dissection of loculated adhesions. Copious drainage of
pus (culture obtained). Wound packed with iodoform gauze. Procedure tolerated without
complications. Wound dressed with sterile 4x4 gauze and paper tape.

Central Line Placement Procedure Note

Consent for procedure was obtained and is in chart. The Patient's right / left ________ was
prepped and draped in usual sterile fashion. 2% Lidocaine was used to anesthetize the area. A
Triple lumen central line was introduced over a wire via the Seldinger technique and the
catheter sutured into place. Good blood flow was noted from the each port. Blood loss was
minimal and the patient tolerated the procedure well without complications. Chest x-ray was
ordered to assess for pneumothorax and catheter placement.

Arterial Line Placement Procedure Note

Allen's test performed to ensure adequate perfusion. Patient's right / left arm / groin prepped and
draped in usual sterile fashion. Lidocaine was not used to anesthetize the area. An 20g Arrow
arterial line was introduced into the radial / femoral artery. Catheter threaded and the needle
was removed with appropriate blood return. Blood loss was minimal. Patient tolerated the
procedure well, and there were no complications.

Endotracheal Intubation Procedure Note

Permit was implied secondary to emergent situation. An LMA and bougie were placed within
arm's reach. A MAC 3/4 blade was inserted into the oropharynx at which time the vocal cords
were visualized. An 8.0 French endotracheal tube was inserted and visualized going through the
vocal cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter.

53
Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 22
cm, measured at the teeth. Portable chest x-ray ordered for confirmation of tube level. Post
intubation sedation ordered.

Lumbar Puncture Procedure Note

Patient positioned, prepped and draped in usual sterile fashion. The L4-5 space was located
using the iliac crests as landmarks. Lidocaine was used to anesthetize the area. A 22G spinal
needle was introduced into the arachnoid space. The stylet was removed with appropriate fluid
return. Needle removed after adequate fluid collected. Blood loss was minimal. Patient tolerated
the procedure well and there were no complications.
Opening pressure (Obtained while patient in lateral decubitus position): <____>
Fluid appearance: <____>
Tube 1: Cell Count
Tube 2: Gram Stain, CSF Culture, Glucose, Protein, Other ...
Tube 3: Pt ID placed and held if further CSF studies indicated
Tube 4: Cell Count

Chest Tube Procedure Note

The patient was positioned appropriately for chest tube placement. The patient’s right <____>
left chest was prepped and draped in sterile fashion. 1% Lidocaine was <____> not used to
anesthetize the surrounding skin area. A 2 cm skin incision was made in the mid-axillary line at
the inframammary crease. Utilizing blunt dissection a subcutaneous tunnel was created
cephalad just adjacent to the superior rib. The pleural space was entered bluntly and gush of air
<____> blood was observed. A finger was inserted into the pleural space to check for anatomy
and guide tube insertion. A 36 <____> 40F thoracostomy tube was inserted using a Kelly clamp
and positioned appropriately. The chest tube was sutured securely to the skin and a sterile
dressing applied. A pleurevac was attached to the chest tube and a chest x-ray obtained.
Estimated Blood Loss: <____>

Procedure Note Sample:

Procedure - Lumbar Puncture
Indication - meningitis
Anesthesia - local 1% lidocaine w/ epi
Informed consent was obtained from the patient's mother. The area was prepped and draped in
the usual sterile fashion. Using landmarks, a 22 gauge spinal needle was inserted in the L4-L5
innerspace. The stylet was removed and the opening pressure was measured at 18 cm of water.

54
4cc of clear fluid was collected and sent for routine studies. CSF was also sent for HSV and
EBV PCR. The patient tolerated the procedure well. There was no blood loss or hematoma.

Admitting Orders

ADC VAAN DIML

 Admitting orders are written with each admitting H and P. Also used for transfer patient
to another part of hospital.
 Flag chart to inform nurse of new orders.

Admit: Attending admitted to, admitting team/service, room number. Ex: admit to recovery
room, admit to MICU, admit to surgical service etc.
Diagnosis: Admitting diagnosis or procedure if postop orders. Ex: Chest pain r/o MI, s/p
cholecystectomy
Condition: Stable, critical, guarded, etc.
Vitals: establish the frequency of vital signs. Ex: vital q shift, vitals q4h
Activity: Specify activity level. OOB as tolerated, strict bed rest, ambulate qid, bathroom
privileges etc.
Allergies: note allergies
Nursing Procedures: Bed position, preps, scrubs, showers, Respiratory care: suction, vent
settings, incentive spirometry, 02. Dressing changes, wound care. Ex:: change dressing bid,
rotate patient q2h, notify house staff if Temp >101ºF, SBP <90 or >160, neuro checks q4h.
Diet: NPO, clear liquid, regular, low salt
Ins and outs: Refers to all “tubes” a patient may have
Record Daily I & O’s
IV Fluids: Type and Rate
Drains: NG to low suction, Foley to gravity
Medications: Order meds
Labs: Order labs

Example of Admitting Orders

Admit To: Cardiac step down unit, Dr. Comando.

8 Achilles, Room 805, Blue Team.
Diagnosis: CAD, S/P PTCA/Stent of LAD
Condition: Stable

55
Vitals: VS including arterial line pressure q15min until sheath pull. Post sheath pull: VS
q15min x 4, q30min x4, q 1h x4 then q4h
Activity: Bed rest. Ambulate with assistance q6h post sheath pull
Allergies: PCN (rash)
Nursing Procedures: Post sheath pull, elevate HOB 30º. Notify House Staff if Temp > 101ºF,
SBP < 90 or >160
Diet: 2gm NA, low chol diet
Ins and Outs: Record daily intake and output
Foley to gravity
Change peripheral IV lines q3days
Medications: Aspirin 325 mg po qd
Clopidogrel bisulfate (Plavix) 75 mg po qd
Amlodipine (Norvasc) 5 mg po qd (hold for SBP<90)
Tylenol 640 mg po q6h prn for pain or T>101º
Labs: CPK-MB q8h x 3, CBC, SMA-7, Dig level in AM, EKG in AM

56
 DIFFERENTIAL DIAGNOSIS

Using Clinical Judgment during the Medical Encounter

Most of the information you need to make appropriate diagnoses and to take care of your
patients comes from the medical encounter. Only rarely can a diagnosis be made with 100%
certainty. Most of the time you will work with probability and likelihood. You can be certain
of your diagnosis only if there is a biopsy that is 100% unequivocal or a test that is
unquestionably diagnostic. This will not be the situation, usually.

You begin forming differential diagnoses while obtaining the patient’s history.
Differential diagnosis is a way of generating hypotheses regarding the identity and cause of an
illness or condition. It is not an end in itself, but rather a route to the specific diagnosis. As you
gather more data from both the history and physical examination, your differential diagnosis
may change. Forming a differential diagnosis is a thought process that involves clinical
judgment.

When forming a differential diagnosis, consider your patient’s symptoms and signs as well as
his/her age, gender, risk factors, past medical history and living situation. The differential
diagnosis almost always involves probability. When you enter the examination room to
interview a 50-year-old female, you immediately know that some illnesses are possible and
some are not. Forming a differential diagnosis involves the following thinking skills:
 Probability: Consider the most common diagnoses first and those that seem to be the most
likely explanation.
 Seriousness: Serious and life-threatening illnesses must be ruled out more aggressively than
mild or self- limited diseases. One would want to consider meningitis, endocarditis, or
subarachnoid hemorrhage even if they are less common if the data suggests these as
possibilities.
 Treatability: Consider diagnoses more seriously if failure to treat would hurt the patient.
 Multiple, competing hypotheses: Avoid making a “snap” diagnosis. Think of a number of
diagnostic possibilities compatible with the chief complaint and data obtained in the medical
interview and physical examination. Eliminate a diagnosis (hypothesis) that fails to
explain the findings.

Cluster Recognition:
Diseases and syndromes are distinctive patterns of clinical findings. If you can recognize a
compelling pattern in a patient’s symptoms, signs or laboratory data, you have discerned a
57
possible diagnosis. Cluster recognition consists of choosing the chief points in a clinical
scenario, connecting them, and associating them with a known disease or syndrome. A young
woman with nausea, fatigue and secondary amenorrhea is likely to be pregnant. These findings
form a clinical pattern that is most consistent with pregnancy.

Writing the assessment: Only include possible diagnoses that are realistic at the end of the
patient encounter. Some assessments that you were considering earlier in the encounter may
not seem realistic at the end of the encounter when you have more subjective and objective
information. Include a differential diagnosis if you are still considering more than one
diagnosis. When you write a differential diagnosis, prioritize listing the most likely and most
serious first.

The Plan:
After a differential diagnosis has been generated, a plan to test and/or treat needs to be formed.
For a reasoned plan to test your hypotheses there should be a reason for each test that you order.
Consider the harm, benefit and cost of each test. Do not order tests whose results will not
logically make a difference in the decision making process. Seek evidence that tends to either
rule out or confirm a diagnostic alternative. There should be a plan for every assessment and
vice versa.

Follow-up:
Includes next appointments, when you will call the patient back with results of tests, why to
come back sooner than appointed, step-wise plans if appropriate for future visits, etc.
The follow-up instructions are usually the last entry in the plan.

Dealing with Uncertainty:

The degree of diagnostic certainty that must be obtained in any particular case is variable and
arguable. At some point you will have to decide when you have obtained sufficient data and
test results to proceed with management. The ability to recognize that you have reached this
point is an important part of clinical judgment. In making this judgment, you must consider the
seriousness of the patient’s condition, disease probability, the age and general condition of the
patient, risks of further tests, and the costs to the patient and society in terms of inconvenience,
money and delayed treatment.

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 ORAL PRESENTATION

As a first year physician assistant student you will be giving oral presentations to faculty. As a
second year student you will orally present each patient to your preceptor or his/her designee.
When you are a certified physician assistant you will present selected patients to your preceptor
and consultants.

The purpose of the oral presentation is to concisely convey to the listener the story of your
patient. The medical workplace is fast-paced, and you must be able to organize your thoughts
quickly and verbally portray your patient in a few minutes. The format is that of the SOAP
note. The chief complaint, present illness and medical history are reported concisely. The
social history, family history and review of systems are reduced to noteworthy findings. The
physical examination report always includes vitals and the general appearance of the patient and
stresses the organ systems most relevant to the patient’s chief complaint. For example, in the
case of a 30-year-old male who presents with periumbilical abdominal pain you would give a
detailed report of the abdominal examination and less detail of other systems examined.
Example:
Chest clear. Bowel sounds present. No abdominal bruits. Mild periumbilical tenderness. No
masses or organomegaly. No guarding or rebound. Rectal exam shows good sphincter tone, no
masses, brown stool present and negative for occult blood. Prostate normal.

The presentation includes a complete assessment and plan. Review the example on the
following page.

It is important not to mix subjective and objective information. The presentation should be
organized so that the listener can easily follow. To develop this skill, it is recommended that
you practice presenting your hospital visit patient. Tape record a presentation, listen to your
presentation, self-critique and re-tape the presentation. Physicians and other health care
professionals will judge your medical knowledge and competence on the basis of your oral
presentations and written medical records.

Cases can be presented in any and potentially all of these 3 formats:

 Comprehensive: complete HPI, PHM, FHX, Soc Hx, ROS, PEX, labs, assessment
including differential, and plan. Not to exceed 5 minutes talking at an understandable
pace.
 Detailed: Relevant features of all elements of presentation, but able to use terms such as
"non-contributory", "unremarkable" for categories. OK to say labs WNL, PE WNL
59
 except for ..... Intention here is to highlight pertinent positives and negatives, but not
specifically mention irrelevant information. Not more than 2 minutes.
 Brief: 30 seconds total. Roughly 1 sentence HPI and PMH. One sentence Physical
Exam and labs. 1 sentence on DDX, assessment, and plan. No more than 6 sentences
total.

EXAMPLE: AMBULATORY CARE ORAL PRESENTATION

Hank C. is a 38 year old white construction worker with no PMHX comes in because c/o
gradual onset of a cough productive of yellow sputum (~1 cup per 24 hours), occasionally
blood-tinged, x 10 days. He states that he was feeling well 2 wks ago when he awoke with a
scratchy throat and clear nasal discharge. Over the following two days his sore throat increased
in intensity and was accompanied by pain with swallowing which have currently resolved. He
has had chills and sweats but has not checked his temperature. The cough keeps him up at
night. He took Nyquil last night without relief. He is concerned that he may have pneumonia.
His children have had colds recently.
Denies SOB/chest pain/ dyspnea on exertion. No history of TB or pneumonia, sinusitis, otalgia,
asthma, wheezing, chronic lung disease or known occupational exposure.
His last PPD was in 9/06 and was negative. The last CXR was 5 years ago and he says that it
was normal. He has smoked one pack of cigarettes a day for 13 years and smokes 3 marijuana
cigarettes a week.

Medical History: He is generally healthy, and denies any major medical problems,
hospitalizations or surgeries. He gets red, itchy eyes and nasal congestion in the Spring, which
he thinks is due to pollen allergy. No allergies to foods or medications. He takes no
medications on a regular basis.
ROS is noncontributory.

Objective:
PE: Febrile at 100.6 PO V/S are otherwise stable.
He is A&O x 3, well-appearing male who was coughing in the exam room.
He has no rash. Conjunctivae are clear without discharge, sclera are anicteric. TMs are clear,
pearly and mobile. There is no frontal or maxillary sinus tenderness. Nares are patent,
turbinates swollen and erythematous, there is clear nasal discharge bilaterally and minimal
crusting in the right naris. Pharynx is mildly injected, tonsils swollen 2+ without exudate.
Uvula midline. No cervical adenopathy. Chest is non-tender and resonant throughout. Rhonchi
heard at the right lung base but was cleared with coughing, and there are no wheezes or rales.
60
Tactile fremitus is normal, bronchophony, egophony and whispered pectoriloquy are negative.
Heart rate and rhythm are regular, S1 and S2 are clear with no murmur or gallop, and there is no
pedal edema.
First on my assessment list is bacterial bronchitis secondary to URI.

Plan – I would treat with Doxycycline 100mg BID for 10 days, acetaminophen 500mg 2 tabs q
–6 hrs prn for fever or pain, Robitussin plain 2 tsps q 4 hrs prn for cough during the day,
Phenergan with codeine 1-2 tsp q hs prn for night cough only. Albuterol inhaler 2 puffs bid
until symptoms resolve. Monitor temperature, increase clear liquids, rest and stay home from
work for 3 days. Smoking cessation was encouraged. He should call, return to clinic or go to
the ED if he experiences shortness of breath, fever of 102 or higher, increased chest pain or
hemoptysis, or if he isn’t improving in 48 hours. I cautioned him about the possible GI side
effects of doxycycline and codeine. I will re-check the bronchitis in 2 weeks and follow-up on
smoking cessation.

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Commonly Used OB/GYN Abbreviations
AB abortion
MAB - missed abortion
SAB - spontaneous abortion
TAB - therapeutic abortion
EAB - elective abortion
ACOG American College of Obstetricians and Gynecologists
AFP Alpha Fetoprotein
MSAFP - maternal serum alpha-fetoprotein
AGUS atypical glandular cells of unknown significance
AMA advanced maternal age
AFI amniotic fluid index
AROM artificial rupture of membranes
ASCUS atypical squamous cells of unknown significance
BBOW bulging bag of water
BBT basal body temperature
BMD bone mineral density
BPD biparietal diameter
BPP biophysical profile
BSO bilateral salpingo-oophorectomy
BTBV beat-to-beat variability
BTL bilateral tubal ligation
CIN cervical intraepithelial neoplasia
CPD cephalopelvic disproportion
CRL crown rump length
CST contraction stress test
CT chlamydia trachomatous
CVS chorionic villi sampling
D & C dilatation & curettage
D & E dilatation & evacuation
DIC disseminating intravascular coagulopathy
DI/DI dichorionic/diamniotic twins
EDC/EDD estimated date of confinement/estimated date of delivery
EFM electronic fetal monitoring
EFW estimated fetal weight
EGA estimated gestational age
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EMB endometrial biopsy
ERT estrogen replacement therapy
FAVD forceps assisted vaginal delivery
FHR/FHT fetal heart rate/fetal heart tracing or tone
FL femur length
FLM fetal lung maturity
FM fetal movement
FSE fetal scalp electrode
FSH follicle stimulating hormone
FTP failure to progress
GBS/GBBS group B beta streptococcus
GC gonorrhea
GDM gestational diabetes mellitus
GIFT gamete intra-fallopian tube transfer
GnRH gonadotropin releasing hormone
G_P_ gravida, para (TPAL - term, preterm, abortions, living children)
GTD gestational trophoblastic disease
HCG human chorionic gonadotropin
BHCG - beta human chorionic gonadotropin (usually serum)
UHCG - urinary human chorionic gonadotropin
HELLP hemolysis, elevated liver enzymes, low platelets
HGSIL high-grade squamous intraepithelial lesion
HPL human placental lactogen
HPV human papilloma virus
HRT hormone replacement therapy
HSG hysterosalpingogram
HSV herpes simplex virus
I & D incision & drainage
ICSI intracytoplasmic sperm injection
IUD intrauterine device
IUFD intrauterine fetal death
IUGR intrauterine growth retardation
IUI intrauterine insemination
IUP intrauterine pregnancy
IUPC intrauterine pregnancy pressure catheter
IVF in vitro fertilization
LCP long, closed, posterior
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LEEP/LOOP loop electrical excision procedure
LGA large for gestational age
LGSIL low grade squamous intraepithelial lesion
LH luteinizing hormone
LMP/LNMP last menstrual period/last normal menstrual period
LOA/LOT/LOP left occiput anterior/left occiput transverse/left occiput posterior
LTC long, thick, closed
LTCS/LVCS low transverse C- section/low vertical C-section
MFM maternal fetal medicine
MVU Montevideo units
NST non-stress test
NSVD normal spontaneous vaginal delivery
NT nuchal translucency
NTD neural tube defect
OCP oral contraceptive pills
OT occiput transverse
PCO/PCOS polycystic ovarian syndrome
PCT post-coital testing
PID pelvic inflammatory disease
PIH pregnancy induced hypertension
PMB postmenopausal bleeding
POC products of conception
POD/PPD post-operative day/postpartum day
PPH postpartum hemorrhage
PPROM preterm premature rupture of membranes
PROM premature rupture of membranes
PTL preterm labor
PUBS percutaneous umbilical blood sampling
PUPPPS pruritic urticarial papules and plaques of pregnancy
ROA/ROT/ROP right occiput anterior/right occiput transverse/right occiput posterior
ROM rupture of membranes
SBE self breast exam
SGA small for gestational age
SROM spontaneous rupture of membranes
SSE sterile speculum exam
STD/STI sexually transmitted disease/sexually transmitted infection
SVE sterile vaginal exam
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TAH total abdominal hysterectomy
TOA tubo-ovarian abscess
TOL trial of labor
TRIPLE TEST MSAFP/HCG/Estriol
TVH total vaginal hysterectomy
US ultrasound
VAVD vacuum-assisted vaginal delivery
VB vaginal bleeding
VBAC vaginal birth after C-section
VAIN vaginal intraepithelial neoplasia
VIN vulvar intraepithelial neoplasia
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