soap note example -cough

soap note example -cough

Please go to Bates’ Visual Guide to Physical Examination at batesvisualguide.com. After logging in, go to the Objective Structured Clinical Examinations (OSCE) tab, log in again, and complete the OSCE titled “Cough”.

Please document this encounter using the SOAP format. Unless specified in the case study, the patient’s PMH, PSH. FH, SH, and ROS are “normal” or non-contributory. Your task is to “create” a “normal” (don’t use that word!) PMH, PSH, FH, SH, and ROS for your documentation for this encounter (See examples in your Bates’ text and pocketbook). In other words, I need to see that you know what information belongs under each of these categories and that you know how to document appropriately. So, create or make up, normal findings for these and document them correctly. Recall these OSCE written assignments are to be Comprehensive SOAP Note. When you document the physical exam you will include any abnormalities discovered in the OSCE but will also include so-called “normal” findings in each system. Here too, what is expected is evidence that you are proficient in communicating both normal and abnormal findings (without using those words!).

Under “Assessment” you will choose the most likely diagnosis which is confirmed by the data presented and assessed. Using the tool found at either http://www.icd10data.com/ (Links to an external site.) or https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx (Links to an external site.) you will also include the ICD 10 code appropriate to that diagnosis. For example, if your assessment for an encounter is “Acute Pharyngitis” you would document this as “Assessment: Acute pharyngitis (ICD 10 Code J02.9)”. For our purposes you will identify (list) the data to the diagnosis which supports it. Please see grading rubric.

The differential diagnoses, as you are aware, are diagnoses which are possible given the data. It is usually listed from the MOST probable to the LEAST probable given the data at hand or data being derived from diagnostics. But they are data driven. If there is no data to support it, the diagnosis should not be considered.

In a patient encounter SOAP note, many clinicians place their differential diagnoses within the “Plan” and keep the current working diagnosis in the “Assessment”. (This is my preference and practice). This helps the biller/coder in the practice quickly identify the current diagnosis without billing for diagnoses which are not confirmed. For example, the data at hand may confirm an abnormal PAP (ASCUS), but you are concerned about cervical cancer. Under the heading of “Assessment”, cervical cancer would not be listed since the data does not yet confirm it. Rather, under section heading of, “Assessment” it would be “Papanicolaou smear of cervix with atypical squamous cells of undetermined significance, ICD 10 Code R87-610)”. But under “Other considerations” or “Differential Diagnoses” in you would obviously communicate your malignancy concern. Here too, you will need to link or document your data which supports the consideration of the differential and provide the appropriate ICD 10 codes).

You will not be documenting the “Plan”, other than diagnostics. Leave the pharmacotherapeutics and surgeries or therapies for your next class. It is beyond the scope of our course. After you have chosen your diagnostic test(s) please indicate what specific finding/result from the test would support (or refute) your diagnostic concerns.

A title page will be necessary and should follow standard APA format. An abstract is not necessary. You may single space the document but please separate the major sections by a double space. Headings should correspond to the major sections of the SOAP format. Please submit your SOAP note using a file upload under Assignments and in the following format: (1) biographical and identifying data, (2) subjective data – with its subcategories, (3) objective data – with its subcategories, (4) assessment, and (5) plan. Refer to your texts and the presentation “SOAP Notes and Oral Presentations” for more detailed information. Please provide a reference page.

See SOAP NOTE FORMAT under “Course Resources and Information” for format to use for the SOAP note

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Rubric
Written SOAP Note Assignments (3)
Written SOAP Note Assignments (3)
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeAPA format and grammar/spelling rules followed
8 pts
This criterion is linked to a Learning OutcomeComplete and accurate biographical data
12 pts
This criterion is linked to a Learning OutcomeSubjective data includes pertinent data including chief complaint, history of present illness, past medical history, social and family/genomic history, past surgeries, and ROS.
20 pts
This criterion is linked to a Learning OutcomeObjective data includes comprehensive physical exam, including vital signs, and completed diagnostics.
20 pts
This criterion is linked to a Learning OutcomeAssessment (with ICD 9 code) is accurate and has supporting subjective and objective data described for the diagnosis.
8 pts
This criterion is linked to a Learning OutcomePlan of care includes “Other Considerations” or “Differential Diagnoses” which are supported by subjective and objective data described for the diagnoses.
20 pts
This criterion is linked to a Learning OutcomePlan of Care includes appropriately chosen diagnostics with description of results which would affirm or refute the diagnoses.
12 pts
Total Points: 100
I will include the soap note example and also the bates video transcript in written format. This transcript also has a differential diagnosis. Please follow the soap note, so all areas are coverd
1
SOAP Note: Cough
NURS 622: Advanced Health Assessment
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SUBJECTIVE DATA
Biographical and Identifying Data
02/18/2021 at 10:00 AM.
Ms. Chen is a 45 year old female of Asian ethnicity. She is single and works as a dispute
mediator.
Current Address: 1532 Elizabeth Street Joliet, Illinois 60431
Phone number: (815) 555-1645
Self referred; reliable evidenced by recalling events easily, having consistent memories
and appearing open and pleasant during interview.
Chief Complaint: “I have been coughing for a week and just can’t seem to stop. I can hardly
sleep at night.” (Bates, n.d.). soap note example -cough
History of Present Illness:
Ms. Chen is a 45 year old female who smokes two packs of cigarettes per day for the past
ten years presenting today with a cough that has been occurring for one week. She reports
the symptoms began a little over a week ago with a runny nose and feeling a drip down
the back of her throat. Since then, symptoms have worsened and she has developed a
cough. The cough produces a yellow- green color with intermittent pink streaks in it that
Ms. Chen reports look like blood. She reports she does not see the pink streaks in every
sputum, but about 3-4 times per day. She denies pain in her chest. She reports the cough
seems to be worse at night and is causing disruption in her sleep. She has tried to sleep on
two pillows at night and reports this helps her head but is not relieving the disruption in
her sleep. Patient denies any fatigue preventing her from performing her activities of
daily living. She is experiencing wheezing and shortness of breath upon exertion during
activities such as walking up the stairs or doing yard work. Denies wheezing or shortness
of breath at rest when working at her desk. She has been taking over the counter (OTC)
decongestants and ibuprofen twice a day. Yesterday she checked her temperature at home
and it was 101 degrees Fahrenheit and fever is still present upon assessment today. She
denies having a history of these symptoms. Affirms she has seasonal allergies to pollen
and goldenrod but these are almost over for the season. Affirms a history of mild
childhood asthma with no hospitalizations or complications. She traveled to Shanghai a
few months ago with no known exposure to any ill people and no symptom development
during that time. She denies weight loss, night sweats or history of tuberculosis. Reports
her grandmother had tuberculosis as a child but was never in contact with patient while
having symptoms. Patient had a negative tb skin test 10 years ago. She denies any acid
taste or reflux symptoms.
Medications: No prescription medications. Patient has been using OTC recommended
dose of decongestant and ibuprofen BID for the past week.
Allergies: No known drug or food allergies. Seasonal allergies to pollen and goldenrod.
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Tobacco Use: Smokes two packs of cigarettes per day for the past ten years with no
periods of successful cessation. No history of using chewing tobacco.
Alcohol and drug use: Patient reports one glass of wine three times per week. Denies
any illicit or prescription drug use.
Past Medical History
Childhood Illness: History of mild asthma as an elementary school aged child with no
hospitalizations.
Adult Illnesses
Medical: Seasonal allergies in fall and spring.
Surgical: No surgical history
Obstetrical: No obstetrical history soap note example -cough
Psychiatric: No psychiatric history
Health Maintenance: TB skin test 10 years ago. All immunizations up to date. Receives
Influenza Vaccine every year, most recently in September 2020. Last pap smear in
January 2020, negative for intraepithelial lesion or malignancy; no HPV detected.
Mammogram in 2019, negative for masses.
Family Medical History: Maternal grandmother positive for tuberculosis when she was
in her 20’s. Currently alive at age 85. Patient denies any other family history of cancer,
respiratory disorders, cardiovascular disorders, kidney disease, diabetes, neurological
disorders, musculoskeletal disorders, gastrointestinal disorders, genetic disorders or
mental illness.
Personal and Social History: Born in Joliet, Illinois into a family with mother, father, and one
sister 2 years older than her. Has lived in Joliet, Illinois for her entire life. Currently lives alone
with 2 cats. Is single, has never been married and has no children.
Sexual orientation and gender identity: Born female, currently identifies as female.
Identifies as heterosexual.
Significant relationships and support systems: Reports being in a monogamous
relationship for about one year and sees him a few times per week. Reports feeling safe
and supported in the relationship. They have many mutual friends through their church
group where they met. Patient is actively involved in her Catholic church. Patient’s
weekly schedule includes church service and activities a few times per week. Patient
reports seeing friends after work for dinner at least twice per week, feels she has a
supportive friend group and states she rarely feels lonely.
Work history and occupation: Currently working full time as a dispute mediator and has
been in this job for about 20 years. Patient identifies her work as stressful but feels
fulfilled by her work. Patient identifies feeling secure in her job and supported by her
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coworkers. Daily hours from 9 A.M. to 5 P.M, Monday through Friday. Denies being
around any ill coworkers or clients that she is aware of. Patient identifies the stress from
this job contributes to her habit of smoking cigarettes as a form of stress relief. Patient
reports her salary provides her a comfortable lifestyle, is in no major financial crisis, and
does not have significant financial stress.
Education: Completed high school. Completed 4 year college degree.
Lifestyle: Patient reports having many social events scheduled throughout the week after
work. Patient reports she rarely eats dinner alone, either meeting with friends, family or
her significant other. She reports no difficulty in keeping up with chores around the
house, enjoys working outside in her garden and with the landscape. Volunteers on the
weekends with her church and in her free time enjoys reading and painting. Patient
reports having adequate levels of energy for her weekly schedule. Reports sleeping
soundly 7-8 hours each night. No sleep concerns prior to presenting illness disrupting her
sleep. Reports her two cats sleep in the bedroom with her.
Travel: Traveled to Shanghai a few months ago with her family. Was fully vaccinated for
this trip, was not knowingly exposed to any diseases or in contact with any ill people.
Nutrition and exercise: Patient reports a well-balanced diet, makes an effort to eat all
food groups within each meal. Eats three meals per day. Prepares her lunch meals for the
week on Sundays. Eats out a few times a week socially, states she does not eat fried or
greasy foods when she eats out. Reports walking on the treadmill for an hour each
morning prior to going to work.
Alcohol and tobacco use: drinks one glass of wine three times per week. Smokes 2 packs
of cigarettes per day. Denies any illicit substance use. Has a cup of caffeinated tea in the
mornings.
Safety measures: No history of injuries or major accidents. Reports she has never had to
be hospitalized for any reason. Pt reports she wears her seat belt every time she is in a
vehicle. Does not own a firearm. Does not have any prescription medicine in the home,
reports a few bottles of OTC medications in an upper bathroom cabinet. Cleaning
materials and other potentially hazardous chemicals are kept separate in a lower cabinet
in the laundry room. Patient reports she wears sunscreen and a hat that shades her face
every day.
Sexual history: Sexual practices include oral and pelvic intercourse averaging two times
per week. One sexual partner within the past five years. Uses condoms for contraception
and for prevention of sexually transmitted diseases. Sexual preference and history with
men.
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Review of Systems
General: Denies history of weight change, fatigue, appetite change, night sweats, fever
or weakness.
Integumentary:
Skin: Denies history of rashes, bruising, dryness, itching, sores, pruritus, skin
discoloration or pigmentation changes, birthmarks, moles, erythema with or
without blistering. No history of lumps or masses.
Hair: Denies history of hair dryness, changes in texture, lice or other infestations,
trichotillomania, scalp rashes or irritation. No history of unexplained hair growth
or loss. soap note example -cough
Nails: Denies history of nail soreness, brittleness, cracking, lifting or injury. No
history of nail discoloration, yellowing, fungal infections, black or white lines.
Denies history of ingrown nails.
HEENT:
Head: No history of headaches, head injury, dizziness, or lightheadedness.
Eyes: Denies history of vision changes. Does not wear corrective lenses. Last eye
exam by her optometrist Dr. Johnson was November 2019. Denies pain, redness,
or excessive tearing. Denies history of glaucoma cataracts, double or blurred
vision, spots, specks, or flashing lights.
Ears: Denies hearing loss, tinnitus, vertigo, earache, infection, or drainage.
Nose: Affirms seasonal allergies in the spring and fall seasons to pollen and
goldenrod. Denies history of frequent colds, nasal congestion, epistaxis,
discharge, rhinorrhea, or postnasal drip or nasal itching. Denies sinus pain or
pressure.
Throat: Denies dryness, sores and lesions on oral mucosa and tongue. Denies
dentures, bleeding gums, and missing, broken, or painful teeth. Last dental exam
3 months ago. Denies hoarseness, frequent sore throat, dysphagia, or halitosis.
Neck: Denies history of lumps, goiter, pain, and thyroid disease or neck masses. Denies
swollen glands or temperature intolerance.
Breasts: Denies history of lumps, pain, discomfort or discharge. Affirms she performs
preventative self-examinations monthly.
Respiratory: Denies history of cough, production of sputum, hemoptysis, dyspnea,
wheezing, pleurisy, bronchitis, emphysema, pneumonia, COVID, tuberculosis, or pain
with breathing. No previous chest x-ray. Childhood asthma, denies any history of
asthmatic symptoms in adulthood.
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Cardiovascular: Denies history of high blood pressure, heart murmurs, palpitations,
chest pain or discomfort, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, syncope,
edema, rheumatic fever. Denies history of angina pectoris, atrial fibrillation, congestive
heart failure, myocardial infarction, dissecting aortic aneurysm, and pulmonary embolus.
No history of electrocardiogram, echocardiography, CT, stress tests, angiography, MRI or
cardioversion.
Gastrointestinal: Denies dysphagia, odynophagia, dyspepsia, anorexia, nausea, retching,
regurgitation, or vomiting. Denies change in bowel pattern or function, color, size, or
caliber of stools. Denies history of diarrhea, constipation, tenderness, pain, anal itching,
tenderness of the rectum, tenesmus, cramping, bloating, food intolerances, straining with
defecation, mucus, exudate, melena, hematochezia, steatorrhea, or acholic stools, excess
flatus, anal intercourse, anal warts, hemorrhoids, or fissures. Bowel movements are
regular, formed, soft, light to dark brown, and occur usually once a day. Has never had
jaundice or hepatitis. Denies liver, gallbladder, or pancreatic trouble. No history of
colonoscopy.
Genitourinary:
Genital: Denies premenstrual tension, premenstrual syndrome, amenorrhea,
dysmenorrhea, polymenorrhea, oligomenorrhea, or menorrhagia. Onset of
menarche at age 14. Menses regular, every 28 days with moderate bleeding,
averaging six tampons daily. Menses last between 4-6 days. Last pap smear done
in January 2020, negative for intraepithelial lesion or malignancy; no HPV
detected. G0P000. Heterosexual orientation, age at first intercourse was 20.
Denies dysfunctional uterine bleeding, bleeding disorders, postcoital bleeding.
Denies history of endometriosis, adenomyosis, pelvic inflammatory disease,
cystocele, rectocele, endometrial and uterine polyps, and fibroids. Denies history
of polycystic ovarian syndrome and ovarian cysts. Denies vaginal discharge,
cervical or vaginal infections, or vaginal itching. Denies dyspareunia, vaginismus,
decreased libido or sexual dysfunction. Denies menopausal symptoms such as, hot
flashes, flushing, atrophic vaginitis, diaphoresis, insomnia or excessive
flatulence. Denies pelvic pain, pelvic floor dysfunction, sexually transmitted
diseases, HPV infection, multiple sexual partners, vulvar lesions, and anal
intercourse. Denies current pregnancy. Denies inguinal hernia..
Urinary: Denies history of urinary track infections, suprapubic pain, dysuria,
urgency, frequency of urination, polyuria, nocturia, incontinence, painful urination
or hematuria. No history of kidney infections or pain.
Peripheral vascular: Denies history of edema, numbness or tingling in extremities.
Denies history of varicose veins, DVT, or leg cramping. Denies history of color,
sensation or size changes in extremities.
Musculoskeletal: Denies low back pain, radiation of pain to lower extremities, buttocks,
or associate numbness, paresthesia, bladder or bowel dysfunction. Denies history of
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cancer, pain at night or at rest, gout, history of intravenous drug use, pain lasting greater
than one month or unresponsive to treatment. Patient denies monoarticular or
polyarticular joint pain. Denies myalgias or arthralgias, or extra-articular pain. Denies
inflammatory joint pain, infectious joint pain, and decreased range of motion, stiffness, or
edema of joint. Denies tenderness, warmth, or redness of joint. Patient denies joint pain
with systemic symptoms such as fever, chills, anorexia, rash, weight loss, or weakness.
Denies joint pain related to other organ systems.
Psychiatric: No history of anhedonia, depression, nervousness, anxiety, PTSD,
nightmares, insomnia, hypersomnia, phobias, memory changes, or suicide attempts.
Neurologic: Denies changes in mood or attention or speech. Denies changes in
orientation or memory or insight or judgment. Denies headaches, dizziness, vertigo,
fainting, or blackouts. Denies any loss of consciousness, syncope or near-syncope. Denies
any generalized, proximal or distal weakness. Denies numbness, tingling, paresthesia,
paralysis, loss of sensation, tremors or involuntary movements or seizures.
Hematologic: Denies history of anemia or bruising or bleeding. Denies history of past
transfusions or reactions.
Endocrine: Denies history of polyuria, polydipsia, or polyphagia. Denies history of
heat/cold intolerance, weight changes, or excessive sweating. No history of diabetes or
thyroid disease.
OBJECTIVE DATA
General Survey: Patient is calm, demonstrates culturally-appropriate eye contact. Patient is
sitting comfortably and does not appear distressed despite elevated respiratory rate. She is alert
and oriented to person, place, and time; and is well-nourished and groomed wearing clothing
consistent with climate.
Vital Signs: Ht: 5 feet 4 inches, Wt: 125 lbs, BMI: 21.5, BP: 130/88 mmHg, HR: 100 bpm, RR:
22 breaths per minute, T: 101.5 degrees Fahrenheit, and denies pain.
Integument: Intact, ethnically appropriate fair color and complexion, warm, dry, smooth and
mobile. Turgor < 2 seconds. No suspicious moles, nevi, lesions, erythema, ecchymosis, petechiae, jaundice or pallor. Hair: Thick, shoulder-length, black, shiny and coarse hair. Well distributed and neatly styled. Scalp clean. No signs of alopecia, excessive dandruff, nits or infestations. Nails: Evenly trimmed, smooth and short with all nail plates intact. No signs of ingrown, paronychia, infections, ridges, thickening, deformities, splitting, injury, clubbing or cyanosis. HEENT: 8 Head: Skull is normocephalic, atraumatic, and symmetrical without deformities, depressions, lumps, or tenderness. Facial expression is relaxed and calm. Features are symmetrical. Face is without edema, involuntary movements, or masses. Neck: Full range of motion of neck with flexion, extension, rotation, and lateral bending. Anterior and posterior triangles of neck symmetrical bilaterally. Trachea midline. Thyroid isthmus palpable. Thyroid gland smooth without masses, enlargement, or bruit. Thyroid gland moves symmetrically upward with swallowing. Lymph Nodes: Preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, and supraclavicular lymph nodes non-palpable and non-tender bilaterally. Eyes: Positioned and aligned symmetrically. Eyebrows move symmetrically without scaliness or lesions. Palpebral fissure symmetrical. Upper and lower eyelids are well approximated without ptosis, lid lag, or lesions. Eyelashes evenly distributed without gaps. Medial and lateral canthus visualized without pain, redness, swelling or drainage. Sclera white. Conjunctiva pink without exudate, nodules, or swelling bilaterally. Lacrimal gland visualized bilaterally without redness, swelling, pain or drainage. Cornea and lens without opacities bilaterally. Irises brown, flat, without crescentic shadow. Pupils round, equal, and reactive to light and accommodation, 4 mm in size constricting to 2 mm in size with light bilaterally. Bilateral vision 20/20 using Snellen chart. Extra-ocular movements are full and coordinated without nystagmus. Confrontation by Static Finger Wiggle Test full, without deficits. Positive red reflex. Fundus exam reveals reddish orange background without hemorrhages, cotton wool spots, or Roth spots; optic disc margins sharp, round and dark yellow. Optic cup is round and light yellow, cup to disc ratio 1:2; arteries red, veins darker red without AV nicking emboli or infarcts, AV ratio 2:3; macula not visualized, fovea lateral and slightly inferior to optic disc, darkened and circular. No papilledema or virtuous floaters noted. Ears: Pinna and skin around bilateral ears, face and scalp intact, without redness or scaling, scars, masses, or lesions. Pinna, tragus, and mastoid process without tenderness. Ear canal clear, without drainage, minimally occluded by soft yellow cerumen. Tympanic membrane pearly gray, intact, mobile, without bulging or retractions. Malleus, umbo, pars tensa and pars flaccida in appearance with cone of light visualized. Gross hearing intact with whispered voice, 4/4 words correct. Weber without lateralization. Rinne bilaterally AC>BC 2:1.
Nose: Midline and symmetrical to the face, tip non-tender to touch. Mucosa pink, without
inflammation, swelling or drainage. Septum midline, without perforations, no evidence of
epistaxis or crusting. Turbinates without edema, erythema, hypertrophy, lesions or
inflammation. Nasal airways patent. Non tender frontal and maxillary sinuses.
Mouth/Throat: No lesions, scaling or cracking on or around lips. Oral mucosa pink,
smooth, without ulcers, nodules, or white patches. Buccal membranes, hard palate, soft
palate pink, moist and intact. Tonsils grade 0. No halitosis. Gums pink and without
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ulcerations or inflammation. 32 adult teeth without discoloration and intact. Tongue
symmetrical, moist, and without lesions, protrudes midline. Sublingual area without
nodules, ulcerations, white or reddened areas. Upper and lower frenulum midline and
intact. Soft palate rises with phonation. Moderate posterior pharyngitis without exudate
or ulcerations.
Thorax and Lungs: Nonlabored tachypnea of 22 breaths/minute. No cyanosis or clubbing.
Thorax symmetrical without deformities, impaired respiratory movements, or retractions. No use
of accessory muscles. No tenderness to pectoral muscles or costal cartilages. Chest expansion is
symmetrical AP: traverse ratio 1:2. No skin lesions, masses or tenderness noted. Symmetrical
lung expansion. Signs of consolidation shown with decreased tactile fremitus over the base of the
left lung along with dullness, egophony and discernable whispered sounds. Rhonchi heard upon
auscultation over base of left lung, right lung clear of adventitious sounds. Diaphragmatic
excursion 4 cm bilaterally. Breath sounds are vesicular throughout bilateral upper lobes, tracheal
breath sounds over the trachea and neck.
Cardiovascular: No jugular venous distention present. The jugular venous pulse is measured 3.5
cm above the sternal angle with the head of the bead elevated to 30 degrees; jugular venous
pressure is estimated at 8.5 cm. Carotids with bilaterally symmetric regular pulses without bruits.
Point of maximum impulse is tapping, palpable and identified visually approximately 2 cm in
diameter located at the left fifth intercostal space on the mid-clavicular line. No observable or
palpable heaves, lifts or thrills. Heart rate at 100 bpm with no audible clicks, murmurs, gallops or
rubs. Crisp S1 and S2 auscultated with S1 loudest at the apex and S2 loudest at the base and with
a physiologically split, with A2 > P2. No S3, S4.
Breasts and axillae: Symmetric. Skin has pink undertones and is smooth. No rashes, lesions.
Areola brown, no retraction of nipple. No deformities in shape when leaning over of flexing the
pectoralis. No tenderness or masses of breast or axillae. Axillary and inframammary lymph
nodes nonpalpable and nontender. No discharge from nipple.
Abdomen: The abdomen is free of scars, striae, dilated veins, rashes, or ecchymosis. The
umbilicus is midline, inverted and free of inflammation or excoriation. The abdomen is
symmetric and rounded with no visible organs or masses. There are no observable peristalsis or
pulsations. Bowel sounds are normoactive in all four quadrants with no bruits, venous hums, or
friction rubs. The aorta is two point five centimeters wide measured in the upper abdomen
slightly left of the midline. No thrills or bruits are noted at the aorta, renal artery, and iliac artery.
The abdomen is tympanic with scattered areas of dullness from fluid and feces. The liver is
approximately four centimeters at the midsternal line and six centimeters at the right
midclavicular line. The splenic percussion sign is negative. The abdomen is nontender with light
and deep palpation. There is a negative cough test and no guarding, rigidity, rebound tenderness,
or percussion tenderness. The liver is non-tender and the liver edge is soft, distinct, regular,
smooth, and is three centimeters below the right costal margin in the midclavicular line on deep
inspiration. The spleen is non-palpable. The kidneys are non-palpable and there is no
costovertebral angle tenderness. The bladder is non-palpable and there is no suprapubic
tenderness.
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Genitalia: Hair is dark brown, coarse and evenly distributed over the mons pubis. No
infestations. Labial skin intact, without lesions, ulcerations or erythema. Urethral meatus is
without swelling or discharge. No enlargement, adhesions, or exudate of the clitoris, Skene’s or
Bartholin’s glands. Vaginal mucosa intact, pink, without inflammation, discharge, ulcerations, or
masses. Cervix round, smooth, pink and midline without lesions, bleeding or discharge. Pap
smear obtained. Uterus midline, anteverted with no enlargement, tenderness or masses. No
adnexal masses. Ovaries 1 cm in diameter, smooth and nontender. Pelvic floor muscles intact.
Rectal: No anal rashes, lumps, ulcers, inflammation, excoriation, internal or external
hemorrhoids, anal warts, perirectal lesions, or fissures. Rectal vault without masses, tenderness,
induration, irregularities, or nodules. Rectovaginal wall intact. Stool brown and hemocult
negative. External sphincter tone is a 3 on a scale of 0-5 on the DRESS scale.
Peripheral vascular and extremities: Warm to touch, no edema present bilaterally. Calves
supple, nontender upon palpation with flexion or extension. No varicosities in lower extremities.
No stasis pigmentation or formation of ulcers. Pulses palpable at +2.
Musculoskeletal: Face symmetrical, TMJ has smooth and full ROM, without redness, swelling,
snapping, clicking or tenderness. Masseters, temporal muscles, pterygoid muscles nontender.
Shoulders symmetrical without flattening or elevation, swelling, deformity, muscle atrophy,
abnormal positioning, or fasciculation. No bulge of subacromial bursa and no skin color change
or unusual bony contours. Subacromial and subdeltoid bursae, supraspinatus, infraspinatus, and
teres minor muscles demonstrate no tenderness or swelling. Full ROM via flexion, extension,
abduction, adduction, internal rotation, and external rotation of shoulder girdle without pain. No
displacement of olecranon process, tenderness, or effusion. Full ROM via flexion and extension
of elbow and full ROM via supination and pronation of forearm. Smooth and natural movements
of hands, fingers slightly flexed when relaxed and fingernail edges are parallel. No swelling,
tenderness, or bogginess over distal radioulnar joint, radiocarpal joint, intercarpal joints, distal
interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, or metacarpophalangeal
(MCP) joints. No deformities or angulation of wrists, hands, finger bones. Thenar and
hypothenar eminences full. No thickening of flexor tendons or flexion contractures of fingers.
Extensor and abductor tendons and snuffbox nontender. No nodules or bony enlargement of DIP
joints. Full ROM of wrists via flexion, extension, adduction, and abduction. Full, smooth and
coordinated ROM of fingers via flexion, extension, adduction, and abduction. Full ROM of
thumbs via flexion, extension, abduction, adduction, and opposition. Posture is upright and
symmetrical. Position of head, neck, and back are erect; with head midline in same plane as
sacrum. No spinal tenderness upon percussion. No increased thoracic kyphosis, scoliosis, or
unequal heights of iliac crests or shoulders, or pelvic tilt. No café-au-lait spots, birthmarks, portwine stains, hairy patches, lipomas, or bony defects of posterior spine. No paravertebral muscle
tenderness or spasm. Full ROM of neck via flexion, extension, rotation, and lateral bending. No
numbness, loss of sensation, tenderness, or weakness of neck or upper extremities. Full ROM of
spinal column via flexion, extension, rotation, and lateral bending without pain or tenderness.
Gait width is three inches from heel to heel. Gait is smooth, continuous rhythm, knee flexed
throughout stance phase and extended on heel strike. Leg length symmetric. No anterior or
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posterior hip atrophy or bruising. No enlarged inguinal lymph nodes, bulges along inguinal
ligament, tenderness of groin, or sacroiliac joint tenderness. Ischiogluteal bursae not palpable, no
tenderness over trochanter. Full ROM of hips via flexion, extension, abduction, adduction,
external rotation, internal rotation. No atrophy of quadriceps muslces, no genu varum or genu
valgum. No swelling of patella, no knee pain or tenderness. No irregular bony ridges along
ribiofemoral joints. No medial or lateral collateral ligament tenderness. Patellar tendon intact,
without tenderness. Patella moves in smooth sliding motion. No thickening, tenderness,
b