Targeted History – Example

SOAP Note

The following is an example of a targeted history written in SOAP format. Please note the distinction between (S)ubjective and (O)bjective findings - and which data belongs in which heading. Note difference between the data in HPI and then data in ROS.

S: >ID: 56 yo widowed white woman who works as a waitress in general good health.

CC: “Burning feeling in stomach”

HPI (history of present illness): Burning in stomach that started 2 mos. ago. Discomfort occurs mainly at night. Associated with nausea and bloating. Denies vomiting. Tums and Mylanta help occasionally. Burning takes all night to go away other times, making it hard to sleep. Denies indigestion. Has had indigestion and it is not the same feeling. Spicy food makes discomfort worse. Denies recent travel, recent infection, regurgance of food, diarrhea, rectal bleeding, black stools, or chest pain. Continues with same bowel habits. No recent weight changes.

PMH: Chole. in ‘89, C. section in ‘76 & ‘78, & plastic surgery for ear tear from fall in ‘93.

FH: mother died @ 71 - MI

father died @ 76 - lung Ca

sister 59 – Type 1 DM & HTN

sister 61 - HTN

brother 57 – Type 2 DM

Habits: Denies smoking, drinking, drug use, exercises 3x/week

Medications: None (prescription or OTC).

Allergies: NKDA, no environmental, food,

ROS:

GI: Has brown, soft, formed stool once per day. Denies vomiting, indigestion, belching, pain, appetite changes, jaundice, swelling, tenderness, diarrhea, constipation, flatulation, rectal pain, hemorrhoids, rectal
bleeding, Denies changes in bowel habits, infections, difficulty swallowing or chewing, or recent travel.

O: Physical Exam:

Abdomen: soft, protuberant, no masses or tenderness. No striae. + Bowel sounds 4 quadrants. No bruits, no rubs. Liver span - 9 cm @MCL. Splenic percussion sign neg. No guarding. Murphy's sign - neg.

A/P: R/O GERD VS PUD [or could do nursing diagnosis]

· Antacids

· H2 Blockers

· Avoid food that make symptoms worse

· Seek medical advice if symptoms worsen

· Return visit - assess treatment

SOAP Note - 2

S:

ID: 63 yo married white male who works as a respiratory therapist in general good health.
CC: “ands are stiff" and "pain in knees."

HPI: Stiffness, achiness, & swelling in hands & joints & pains in knees with movement. Usually occurs in the morning. Lasts app. 2 hr. and then pain and swelling start to subside as day progresses. Denies pain to touch. Has been getting worse over past 2 to 3 yr. Rainy or cold days make stiffness & pain worse. Submerging hands in warm water helps with stiffness. Motrin helps with swelling & pain. Sometimes has difficulty buttoning clothes in morning. No other limitations in movement. Denies infection, loss of sensation, recent fractures, renal disorders, or family history of arthritis.

PMH: Appy in ‘54, MVA with fx of nose and L ankle in ‘62, & depression with group therapy from ‘59 - ‘65.

FH: mother died @ 72 - MI

father 75 - CVA & HTN

sister 57 – Type 2 DM

daughter died @ 18 - pneumonia

Habits: Smoker (69 pk yrs). Denies drinking, drug use, or exercise.

Allergies: NKDA. Denies environmental, food, or animal allergies.

ROS:

Musculoskeletal: c/o joint stiffness, joint swelling, & limited movement in fingers and hands in the morning. Associated b/l knee pain and limited movement without swelling that makes gait stiff. R handed. MVA in past with L ankle and nasal fx. No residual effects from MVA. Good posture. Denies exercise, muscles weakness, cramping, spasm, tremors, deformities, crepitus, flat footedness, coordination problems, back stiffness, dislocations, joint disease, bone disease, or joint clicking.

O:

Physical Exam:

MS - Hands - Limited ROM with adduction & abduction of fingers and thumb bilaterally. Finger flexion limited to 30 degrees L & R. Wrist full ROM R & L. 1-4 th interphalangeal joint slightly enlarged. No tenderness on palpation. Joint surfaces smooth - no nodules. Neg Herbeden or Bouchard nodes. Neg Tinel or Phalen's sign.

Legs - Full ROM hips R & L. No swelling or heat noted.

Knees - Left - Limited flexion to 45 degrees. Full extension. + ballottment, - bulge sign, Neg McMurray Test, Neg Drawer test.

Right Knee - Full ROM, Full extension. neg ballottment, - bulge sign, Neg McMurray Test, Neg Drawer test.

A/P: Osteoarthritis vs Gouty Arthritis

· Uric Acid Level

· ASA

· NSAIDS

· Heat

· Encourage Activities

· Return Visit - assess treatment

Ó ERGiardino 2000