Notes: I wrote this little thing in response to the documentation challenge on dsflashfiction. A SOAP Note is the way health care providers organize their notes on a patient or client. S stands for Subjective, or the things the client tells you, like their medical history. O is Objective, or the facts of the exam itself--what their blood pressure was, whether their lungs were clear or not. A is Assessment, or the conclusions you reach (e.g., this patient may have diabetes). P is Plan, what you're going to do about your findings (e.g., send them for a glucose tolerance test).

I had a lot of fun writing this, although I had to keep reminding myself that I was writing about a man. Because, hey, midwife.

Beta thanks to Ardent and Bast.

Feedback me at bodge38@earthlink.net

by shell

Pt's Name: Ray Kowalski MR# 966534

Date/Time: 7/12/03 4:30 pm

S:

CC: 43 yo WM presents for annual physical. Denies probs/questions.

Med. Hist.: Usual childhood diseases. + frostbite L great toe 1998, no amputation. + broken arm age 8; broken nose age 20; gunshot to abdomen, 1989; dogsled accident 2000 (stitches R leg, no broken bones).

Surg: Abdominal (remove bullet) 1989, no complications, no probs. with anesthesia.

Hosp: 1989, see above.

Fam. Hist.: + HTN (F, PGF, PGM), + prostate cancer (MGF), + breast cancer (MGM), + DM (PGM), + osteoarthritis (PGF, PGM, MGM).

Social Hist.: Imm. from US in 1998 to be with current partner, who is RCMP officer. Works in snowmobile repair and "odd jobs." Former police officer. Ed: 14 years. Divorced; going to Toronto in 2 wks to marry current (m) partner.

Sex. Hist: Bisexual; has been with current partner x 5 yrs. Uses condoms. States he and partner have both been tested and are HIV negative.

Denies phys/sex abuse.

Allergies: NKMA; environmental (cats).

Exercise: dogsledding, snowshoeing, walking.

Denies smoking/drugs, states occ. beer.

Meds: Occ. ibuprofen or tylenol; states occ. uses salve made by partner for sore muscles/joints.

24 hour diet recall: coffee with smarties, cereal with milk, pizza. States eats better when partner is not on patrol.

O: BP 126/74, P 85, T 97.9 oral, RR 16

Ht: 5'11 Wt: 160 BMI 22

Gen'l: Pleasant, thin, no apparent distress.

HEENT: Wears glasses, otherwise WNL, no thyromegaly, no lympadenopathy. Teeth in good repair.

Heart: RRR; S1, S2; no murmur.

Lungs: Clear to auscultation, resp. easy & unlabored.

Neuro: Grossly intact; reflexes +3 bilat.

Skin: Pink, warm; scar L great toe, R thigh, lower R abdomen. No varicosities. Tattoos R shoulder, L hip.

Abd: NT, no organomegaly. Surgical/gunshot scar well approximated, no keloids.

Back: No scoliosis, - CVAT.

Extremities: Normal ROM; - Homan's; + crepitus bilat. knees. No clubbing of fingers, capillary refill <3 sec.

Genitalia: Normal male, testes non-enlarged, symm., no masses, no hydrocele.

Rectal: prostate NT, non-enlarged; guaiac -.

A/P: Phys. exam WNL except mild arthritis both knees.

Advised cont. weight bearing exercise, good diet, incr. protein and calcium intake, importance of incr. intake in this climate. Given info on testicular self-exam, revised food pyramid. Advised biannual PSA due to family history of prostate cancer.

Labs: PSA, CBC, lipid profile.

RTC 1 year and prn.

--C. Maclean, NP, MS

Abbreviations:

CC: chief complaint

HTN: hypertension

DM: diabetes mellitus

NKMA: no known medical allergies

BMI: body mass index

WNL: within normal limits

HEENT: head, ears, eyes, nose, throat

RRR: regular rate and rhythm

NT: non-tender

CVAT: costo-vertebral angle tenderness

ROM: range of motion

PSA: prostate specific antigen

CBC: complete blood count

RTC: return to clinic

prn: as needed