Question: Using a friend, family member, or colleague, perform a...

Question:

Using a friend, family member, or colleague, perform a neurovascular (include all cranial nerves), musculoskeletal, and cardiopulmonary (includes the heart, lungs, and peripheral vasculature) exam. Document the physical examination findings in the SOAP note format. 

Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included.  You may include the assessment and plan portion of the SOAP note, but these sections will not be graded.

You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of headache, back pain, or cough. You should also focus the ROS based on the patient's chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.

SOAP Note Format
Patient Information:
Initials, Age, Sex, Race, Insurance
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own
words - for instance "headache", NOT "bad headache for 3 days”.
HPI : include all the information regarding the CC using the OLDCART format. If the CC was
“Unintentional weight loss”, the OLDCART for the HPI might look like the following example:
Onset: 2 months ago
Location: Generalized
Duration: Steady weight loss, 3-5 pounds per week
Characteristics: Associated with feeling tired, poor appetite, and occasional nausea
without vomiting
Aggravating Factors: Food smells increase the frequency of nausea
Relieving Factors: Small, bland meals are better tolerated
Treatment: None reported
Current Medications : include dosage, frequency, length of time used and reason for use; also
include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately.
PMHx : include immunization status (note date of last tetanus for all adults), past major
illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx : include occupation and major hobbies, family status, tobacco & alcohol use, any other
pertinent data. Always add some health promo question here - such as whether they use seat
belts all the time or whether they have working smoke detectors in the house.