Florida National University Physical Examination Worksheet

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Florida National University

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SOAP NOTE Patient Initials: Date: Allergies: SUBJECTIVE CC: Pt. Encounter Number: Age: Sex: Advanced Directives: HPI: Describe the course of the patient’s illness: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment: Current Medications: PMH Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: Family History: Social History: ROS General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological SOAP NOTE Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE Weight BMI Height PHYSICAL EXAMINATION General Appearance Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Musculoskeletal Neurological Psychiatric Lab Tests Temp Pulse BP Resp SOAP NOTE Special Tests Diagnosis • Primary Diagnosis▪ Evidence for primary diagnosis should be documented in your Subjective and Objective exams. o Differential Diagnoses- Include three diagnoses PLAN including education o Plan: ▪ Further testing ▪ Medication ▪ Education ▪ Non-medication treatments ▪ Referrals ▪ Follow-up visits References
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1

Soap Note

Student’s Name
Institutional Affiliation
Course
Date

2

PERSONAL INFORMATION
Patient Initials: JM
Pt. Encounter Number: 3
Date: 12/1/2021
Age: 28
Sex: M
Allergies: pollen &dust
Advanced Directives: physical examination
SUBJECTIVE
CC: Mr. JM reported lower back pain which has persisted for the past one month; at a time, the
pain radiates to his left leg. The patient also added that at a time, one or both knees click with
catching pain under the patella.
History of Present Illness (HPI):
JM visited our health facility complaining of lower back pain, which always radiates to the legs.
He added that the pain started one month ago and has persisted to date. According to the patient,
the back pain worsens when he participates in heavy activities like manual work. The pain is
always radiated and eases when he is relaxing. The mild the pain relief when the patient is
relaxing and when he takes ibuprofen
Current Medications: the patient is currently not under medication but taking ibuprofen to
relieve him from pain
Past Medical History
Medication Intolerances: no serious medical intolerance
Chronic Illnesses/Major traumas: no chronic illness

3

Screening Hx/Immunizations Hx: all immunizations are up to date
Hospitalizations/Surgeries: recorded minor surgery during circumcision, denied being
hospitalized for serious illness
Family History
The mother is 55 years and has high blood pressure. Daddy died at the age of 60 due to a car
fortune. Sister and brother have no medical issues. Maternal grandmother died at 70 from a
stroke. Maternal granddad died at the age of 78from kidney problems. Paternal grandfather died
due to cancer at 65. Paternal grandma is alive.
Social History
JM does not smoke tobacco but reported drinking alcohol occasionally on the weekends. The
patient Denies taking part in regular exercise and consumes two liters of water daily. The patient
always wears a seat belt while traveling, and he has working smoke detectors around his house.
REVIEW OF SYSTEMS
General: Mr. JM Denies fatigue, fever, and reports losing weight
Car...


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