SOAP operas: Medical Hx, Px, and Chart Interpretations

1
SOAP operasMedical Hx, Px, and Chart
Interpretations

• Andrew Reisman, MD, ATC
• C.A.Q. Sports Medicine
• PHYT-801

2
Objectives

• Learn the basics of a medical history and
  physical examination
• What does this say?
• Understanding medical terminology 101
• Chart Communications

3
Admission History and Physical

• Provides the reader with a thorough account of
  recent and past events in a patients medical
  history
• Details a complete physical examination at time
  of admission
• Occasionally a truncated version is used for
  specific purposes
• Pre-operative physical
• Pre-procedure physical

4
Identifying Data

• ID Identifying data
• Identifies the patient to the reader in a brief
  way
• Age
• Sex
• Race
• Ethnicity
• Occupation
• Residence

5
Identifying Data - Patient ET

• ID ET is a 35yowf stock analyst from suburban
  Philadelphia

6
Chief Complaint

• CC Chief Complaint
• What is the patients stated reason for being
  here
• Generally quotes or paraphrases the patient

7
Chief Complaint - Patient ET

• CC I have a headache
• Sometimes ID and CC are combined into one line
• ID/CC 35yowf here for evaluation of a headache

8
Source of History

• Only occasionally used
• States from whom or where the history was
  obtained
• Generally more relevant in patients who are
  unable to answer questions or if a family member
  is acting as a translator
• Often will quote old chart records

9
Source - Patient ET

• Information was obtained directly from the
  patient who seemed to be a reliable source.
  Additional information was obtained from old
  hospital records.

10
History of Present Illness

• HPI History of Present Illness
• Gives a brief chronological course of events
  leading up to this visit or admission to the
  hospital
• Should follow two basic principles
• KISS
• Five Bs

11
History of Present Illness - Patient ET

• HPI This 35yowf with PMHx significant for HTN
  and DM presents with a 3d Hx of Bilateral
  throbbing head pain. She stopped taking her
  medications 4 days ago because she wasnt sure if
  they were doing anything for her. The pain is
  constant in nature. Denies visual disturbances.
  ( -) n/v/d. Worst headache of her life. Does
  not usually get headaches. Denies fevers. (-)
  photophobia

12
Past Medical History

• PMHx Past Medical History
• Thorough review of all past medical concerns and
  hospitalizations
• Operations listed separately unless specifically
  relevant to episode

13
PMHx - Patient ET

• Hx of Type I DM since age 4
• Episode of DKA age 21 2o UTI
• Hospitalized at Down State U for 5 days
• Hx of Hypertension, Dx age 25
• Multiple admissions for atypical chest pain
• All at this institution 6/97, 7/99, 5/00
• Had asthma as a child

14
Past Surgical History

• PSHx Past Surgical History
• Lists any and all surgical procedures during
  patients life
• Should list who the surgeon was and where the
  operation was done if known

15
PSHx - Patient ET

• TA age 4 Dr. Knife at Merciless Memorial
• Appendectomy age 7 - Dr. Killame at Weteach U.

16
Obstetrical/Gynecological History

• OB/GYN Hx Obstetrical/Gynecological History
• GGravida - Number of pregnancies
• PParity - Number of babies delivered
• TPAL
• Term How many children were delivered near the
  expected due date
• Premature How many were delivered before 37 wks
• Abortions Spontaneous or induced
• Living How many are currently alive
• Onset of menarche and menopause if applicable

17
OB/GYN History - Patient ET

• OBHx G4P2022 NSVD X1 and LTCS X1
• LMP 10 days ago, Nl flow and duration, 28 days
• Menarche age 12
• So this patient was pregnant four times, has
  delivered two children, and has had two abortions
  (either spontaneous of induced)
• NSVD Normal spontaneous vaginal delivery
• LTCS low transverse C-section (should also be
  listed in PSHx)

18
Childhood History

• Childhood History
• Reviews
• Birth History
• Childhood Illnesses
• Immunization History

19
Childhood Hx - Patient ET

• Born at 35 wks EGA w/o complications
• IZ UTD
• Chicken pox age3

20
Review of Systems

• ROS Review of Systems
• This is information generally, but not
  necessarily, related to the HPI
• Often pertinent positives are included in the HPI
• If listed this way, author will often state ROS
  is non-contributory
• Will provide a system by system review

21
ROS - Patient ET

• ROS Significant for ()tinnitus (-)thyroid
  problems occas CP and SOB, particularly with
  exertion (-) abd pain long standing back
  pain without change sugars have remained
  stable denies paresthesias or weakness wears
  glasses.

22
Medications

• Hopefully will provide an inclusive lists of all
  prescription and OTC medications/supplements the
  patient is taking
• Frequently, woman forget that birth control pills
  are a medication
• People generally do not tell about nutritional
  supplements or vitamins unless asked

23
Medications - Patient ET

• Insulin 70/30 human
• 24 Units SQ Qam
• 12 Units SQ Qpm
• Insulin Regular Human
• 12 Units SQ Qam
• 10 Units SQ Qpm
• Adjusts via sliding scale
• Atenolol 50 mg PO QD
• HCTZ 25 mg PO QD

• Chromium Picolinate 2Tabs BID
• MVI 1PO QD
• Gingko Biloba PRN
• GNC Fat Buster

24
Allergies

• A list of both medicinal and environmental
  allergies
• Separate out true allergies vs adverse drug
  reactions
• Generally focuses on medication induced
• NKDA No Known Drug Allergies
• Pay close attention to specific environmental
  concerns such as a latex allergy

25
Allergies - Patient ET

• NSAIDs with question of swelling and respiratory
  difficulties
• Ultram makes her feel weird
• No known environmental allergies

26
Social History

• SH Social History
• Gives us information about the patients
• family
• occupation
• hobbies
• habits
• Religious beliefs

27
Social History - Patient ET

• SH Pt is married to her husband Stefan for 5
  years. They have 2 children, Marliece age 7 and
  Troy age 2. She was divorced once, 6 years ago.
  She has a 40 pack year hx of tobacco abuse
  smoking 1.5-2ppd. She states she is a social
  drinker, drinking a 12 pack on weeknights with
  her friends. Denies IVDA. Patient works as a
  stock analyst. She does frequent craft work at
  home, often using a glue gun.

28
Family History

• Lists significant illnesses in close family
  members
• Cause, age, and date of death of relatives
• Sometimes done as a family tree

29
Family History - Patient ET

• Father committed suicide 6/95 at age 57
• Had history of DM and HTN
• Mother with Hx of frequent headaches, otherwise
  healthy
• Paternal Grandfather with multiple CVAs, died age
  60

30
(No Transcript)
31
Physical Examination
32
Admission Physical Examination

• Packed with information but often difficult to
  interpret due to abbreviations
• An important frame of reference for all future
  physical exams
• Should be closely scanned for pertinent findings
  prior to your evaluation to help avoid the
  unexpected and provide baseline expectations
• Usually done in a standard sequence

33
Physical Examination

• PE Px Physical Examination
• Beware ! !
• (PE also pulmonary embolus or pulmonary edema)

34
General Appearance

• Describes the general state and appearance of the
  patient
• Well vs ill
• Level of distress
• Chronological Age vs appearance
• Race/ethnicity

35
Appearance - Patient ET

• 35 yo ill appearing wf in moderate discomfort who
  appears older than stated age

36
Vital Signs

• VS Vital Signs
• Temperature
• Fahrenheit vs Celsius
• Oral vs Rectal vs Tympanic vs Axillary
• Blood Pressure
• Heart Rate
• Respiratory Rate

• Pulse Oximetry
• Orthostatic Vital Signs
• BP and Pulse in supine, sitting, and standing
  position
• Height
• Weight

37
VS - Patient ET

• VS 38oC, 210/96, 110, 20, SaO2 97 on 2l NC

38
HEENT

• HEENT Head, Eyes, Ears, Nose and Throat Exam
• Includes
• General Appearance
• Pupilary Reflexes
• Eye Movements
• Fundoscopic and Otoscopic Exam
• Oral Cavity
• Nasal and Sinus Exam

39
HEENT - Patient X

• NC/NT, PERRLA, EOMI, Fundoscopic exam with few
  hemorrhagic changes, TM wnl, OP wnl, (-) sinus
  tenderness, nasal mucosa inflamed, visual fields
  full by confrontation

40
Neck Exam

• General Appearance
• Lymph nodes
• Pulses
• Bruits
• Motion

41
Neck - Patient ET

• Symmetrical, (-) lymphadenopathy, (-) carotid
  bruits with 2 Carotids B, (-) JVD

42
Pulmonary Exam

• Describes presence of and type of breath sounds
  heard (auscultation).
• Usually preceded simply by lungs

43
Pulmonary Exam - Patient ET

• Lungs - CTA P, (-) wheezes, Nl IE ratio

44
Cardiac Examination

• Describes pattern of heart beats
• Denotes the presence of murmurs
• location
• R 2nd ICS aortic murmur
• L 2nd ICS pulmonic murmur
• LLSB Tricuspid murmur
• Apex Mitral

45
Cardiac Examination (Contd)

• Type of murmur
• Graded I-VI/VI
• I/VI barely audible
• VI/VI can be heard across the room without a
  stethoscope
• Occasionally pictographs are used
• Preceded by Heart, CV, or drawing of a heart

46
Cardiac Exam - Patient ET

• Heart - RRR, -m/r/g, PMI 5th ICS in midclavicular
  line

47
Breast Exam

• Describes generally appearance and texture of the
  breast
• Medicaid and most insurance guidelines require
  documentation of current or recent exam in
  hospital chart of all female patients
• Will often see stamp in chart placed by medical
  records
• Physicians often write deferred unless directly
  relevant

48
Breast Exam - Patient ET

• Symmetrical w/o masses, (-) lymphadenopathy,
• (-) discharge

49
Abdominal Exam

• Denoted by GI
• Describes
• General appearance
• Presence or absence of bowel sounds
• Areas of tenderness or pain
• General evaluation of organ size

50
GI - Patient ET

• GI Scaphoid, () BS, Soft, NT, ND, (-)HSM
• Other possibilities
• liver percusses to 15cmin R MCL (Nl lt12)
• rebound and involuntary guarding

51
Genital and Urinary Exam

• GU Genital and Urinary
• Obviously differs in male vs female patients
• Male Exam
• Circumcised vs uncircumcised
• Describe number of and contour of testicles
• Hernia check

52
Genital and Urinary Exam

• Female Exam
• Describe external genitalia
• Describe speculum exam
• Appearance of cervix
• Bimanual exam
• Cervical motion tenderness
• Ovarian discomfort
• Size of uterus
• Again, documentation of this exam is required by
  multiple sources

53
GU Exam - Patient ET

• GU Nl external genitalia, Cervix wnl, uterus
  non-palpable, (-) adnexal tenderness, Nl rectal
  tone, Guaiac (-)

54
Rectal Exam

• In female patients, generally covered under GU
• External appearance
• Tone
• Particularly important in spinal cord patients
• Presence or absence of blood
• Hemoccult testing
• Prostate exam

55
Back Exam

• General appearance
• Kidney check
• Areas of tenderness
• Often included with abdominal or musculoskeletal
  exam
• Particularly important in older or immobile
  patients for wound care

56
Back Exam - Patient ET

• (-) Scoliosis, (-) CVA tenderness, (-) skin
  breakdown

57
Extremities

• Briefly describes any abnormalities of the
  extremities
• Appearance
• Range of motion
• Special Tests
• Sometimes will also include neuro and peripheral
  vascular component

58
Extremities - Patient ET

• Ext Symmetrical with full ROM (-)edema, unable
  to evaluate gait.

59
Neurological Exam

• Reviews
• Patients state of cognition
• Cranial Nerves
• Motor function
• Sensory function
• Reflexes
• Stickman

60
Neuro - Patient ET

• Patient AOX2 (unable to state date), Able to
  perform serial 7s X3, Able to remember 1/3
  objects at 3 minutes. Able to follow complex
  commands. CNII-XII grossly WNL, Motor with 3
  RLE strength, hyper-reflexive patellae and
  achilles reflex on R, RUE, LUE, LLE WNL for
  strength and reflexes . Sensation is grossly in
  tact.

61
Vascular

• Describes peripheral pulses on scale of Tr-4 with
  2/4 generally considered normal.
• Denotes presence or absence of bruits when
  appropriate
• Reviews venous state as well
• Stickman

62
Vascular Exam - Patient ET

• Vasc 2 pulses throughout. Good cap refill.

63
Skin

• Important to note when reviewing chart
• Will give you general sense of patient well-being
• Pay attention to skin breakdown or wound care
  issues
• Remember, skin is the largest organ of the body

64
Skin - Patient ET

• (-) lesions, in tact.

65
Laboratory Evaluations

• Frequently coded in Dr. speak shorthand
• gt-lt
• ---lt or --lt
• Chemistries
• Chem 7/SMA 7/SMAc/SMA12/LFTs
• Hematology
• CBC

66
Laboratory Evaluations

• Urine
• UA
• Blood Gasses
• ABG
• ID
• cultures

67
Radiology

• plain films
• CT scan
• MRI
• Angiography
• Nuclear Studies
• Ultrasound

68
Lab Studies - Patient ET

• 18.3gt12.3/38lt325k
• 131/4.2108/2022/0.9lt325
• LFTs WNL
• ABG - 7.31/31/75/95 on 2lncO2
• U/A - SG - 1.010, -WBC, -RBC, Tr Leuc, -ketones
• CXR - NAD
• CT scan - midline shift to the R with loss of
  normal gyri, blood in L ventricle

69
Assessment and Plan

• The summation of everything described above
• When reading a chart, you should focus on the HPI
  and the A/P
• States what the treating physician feels is going
  on (and in a well written note why)

70
Assessment and Plan

• Will give you plan of action to treat the various
  findings and should let you know where you fit
  into the picture
• Sometimes divided into a problem list with most
  severe problems first followed by other concerns
• Frequently combined and described in a narrative
  form

71
Assessment and Plan - Patient ET

• 35yowf who presented with progressive headache.
  CT scan revealed an intraventricular hemorrhage
  on the left side with physical findings c/w a
  left sided CVA yielding weakness in the RLE and
  some confusion. CVA likely secondary to rebound
  of her hypertension after patient stopped taking
  her B-blocker and other antihypertensive
  medications. Will admit patient for
  stabilization of her BP. PT/OT/Speech consult
  once patient stable. ? Neuro consult.

72
Assessment and Plan - Patient ET

• We will continue to monitor her glucose carefully
  and place her on a sliding scale regimen.
  Consider endocrine consult if unable to control.
  
• Patient may need help with nicotine withdrawal
  however do not wish to sedate while evaluating
  her post CVA
• Social work consult for D/C planning

73
SOAP notes

• This constitutes the daily progress note and will
  be the primary form of communication in the
  chart.
• S Subjective
• What has happened in the last 24 hours

74
SOAP notes

• O Objective
• Review vital signs for the past 24 hours
• Describes current physical exam
• Targeted to systems of concern
• Reviews new lab data

75
SOAP notes

• A Assessment
• How the author feels things are progressing
• Often done as a problem list
• P Plan
• What interventions are planned for the next 24
  hours based upon all of the above data
• A/P often combined
• Again, this is the meat of the data and should be
  reviewed daily

76
Confidentiality

• Remember ! ! ! All patient information is
  confidential
• Do not discuss anything about the patient where
  others can overhear
• Even vague descriptions may be recognized by a
  family member in the elevator or cafeteria line

77
(No Transcript)
78
Evaluation of Medical Testing

• Sensitivity
• Probability that a person having the disease
  will be correctly identified by a clinical test
• Specificity
• Probability that a person not having the disease
  will be correctly identified by a clinical test

79
Evaluation of Medical Testing
80
Evaluation of Medical Testing

• Sensitivity
• TP/(TP FN)
• Specificity
• TN/(TN FP)

81
Evaluation of Medical Testing

• Predictive Value
• How likely is the result to be true or false
  based upon the result of a test
• Positive Predictive Value
• Given a result, how likely is the result to
  truly be
• TP/(TP FP)
• Negative Predictive Value
• Given a negative result, how likely is the result
  to truly be negative
• TN/(TNFN)

82
Evaluation of Medical Testing

• Prevalence
• Prior Probability
• All patients with the disease out of the total
  number of patients tested
• TPFN/Total number of people tested