AdvancedHealthAssessment_Comprehensive_SOAP_WrittenGuide.docx

Rash lumps sores itching dryness color change δ in

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Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Head Headache; head injury; dizziness or vertigo Eyes Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma Ears Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use Nose/ Sinuses Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain Throat/ Mouth Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste Neck Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion Breasts Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area Pulmonary Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis,
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nocturia; H/O murmurs, hypertension, anemia, or CAD G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance GU Frequency; nocturia; urgency; dysuria; hematuria; incontinence Females: Use of kegal exercises after childbirth; use of birth control methods; HIV
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