AdvancedHealthAssessment_Comprehensive_SOAP_WrittenGuide.docx

Exposure menarche frequencyduration of menses

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exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding; Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often Peripheral Vascular Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers Musculo- skeletal Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease Neuro Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations Heme Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria;
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glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution Psych Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses II. Objective Data General: Skin: HEENT & Sinuses: Neck & Regional Lymph Nodes: Breasts:
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Lungs & Thorax: Heart: Gastrointestinal: Genitourinary: Extremities (Peripheral Vascular): Musculoskeletal: Neurological:
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III. Assessment A: Differential Diagnosis (include rationales and cite sources) 1.
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