Soap Note

Subjective:
Reason for visit:
HPI

Objective:
General Survey
Patient is a 33 year old white female in no acute distress.
Appearance is well groomed. Dress to current climate
condition. Patient is alert and oriented x 3. Gait is steady
without limps or weakness. No assistive device. Speech is
appropriate without slurs or abnormalities. Comprehension
intact as evidenced by verbal and nonverbal communication.
Vital Signs:
HEENT:
Head/Face: Atraumatic and normocephalic without lesions,
lumps or deformities. Temporal arteries not palpable bilaterally.
No TMJ clicks, popping or crepitation bilateral. No maxillary
and frontal sinus tenderness bilaterally.
Eyes: Symmetric. No lesions or crustations bilaterally.
Conjunctivae, sclera and cornea clear with no erythemia or
lesions bilaterally. PERRLA. Corneal light reflex present in
both eyes, even bilaterally. EOM intact. Peripheral vision
intake bilaterally. No nystagmus bilaterally. Red reflex present
bilaterally.

Ears: Symmetrical without lesions, masses or drainage Nontender bilaterally. Tympanic membrane is pearly grey. TM
landmarks visualized bilaterally. Cone of light 5:00 on right and
7:00 on left. Whisper test intact bilaterally.
Nose: Symmetric. No deviated septum. Nares patent
bilaterally.
Mouth / Throat: Lips symmetrical, pink without swelling or
lesions. Buccal mucosa pink and moist without lesions or
tenderness. Teeth and gums intact with no tenderness. Tongue
is midline with no tremors. Palate and uvula midline, rises
symmetrical. CN X intact. Tonsils 1+ bilaterally. Trachea is
midline.
Neck: Neck is symmetrical, no abnormal pulsations noted. No
masses, lesions or tenderness. Trachea is midline. Carotid
arteries 2+ even, regular bilaterally. No lymphadenopathy
noted. FROM intact.
Thoracic (Posterior and Lateral): Thoracic is symmetrical
with no abnormal retraction. AP < transverse. Color is pale
pink, warm and dry to touch. No lesions, masses or tenderness
anteriorly /posteriorly. Expansion 1 inch. Tactile fremitus is of
normal intensity and equal bilaterally. Percussion tone is
resonant to all fields posteriorly and anteriorly. No CVA
tenderness bilaterally. Respirations unlabored and even with no
adventitious sounds noted.
Thoracic (Anterior): Brown, warm, dry and symmetrical
without lesions. Breath sounds clear bilaterally with no

adventitious breath sounds, no use of accessory muscles. No

retraction. Lungs resonant, with clear breath sounds bilaterally,
no adventitious sounds throughout lung fields.
Cardiovascular: Skin warm and dry to touch, no abnormal
pulsations, heaves or thrills noted on anterior chest. Carotid
arteries 2+ regular, even bilaterally. Apical HR 60 beats per
minute, 2+ regular. No murmur present. S1, S2 present.
Abdomen: Skin brown, warm and dry to touch. Abdominal
convex-round. Umbilicus is midline and inverted, no visible
pulsations noted. No vascular sounds present in aorta, renal or
iliac arteries bilaterally. Abdomen soft, nondistended,
nontender, BS present with 6 BS per minute. Tympany present
in all 4 quadrants.
Upper Extremities: Skin is warm, smooth, brown and dry to
touch. Shoulders, arms, elbows, hands and wrists symmetric.
FROM bilaterally. Epitrochlear nodes not palpable bilaterally.
Capillary refill brisk < 3 seconds. No clubbing or cyanosis
bilaterally. No crepitation, erythema, edema or tenderness
bilaterally.
Lower Extremities: Symmetrical. Skin is warm, smooth and
dry and bilaterally. No lesions or edema noted. Hair distributed
evenly. Popliteal pulses not palpable bilaterally. Posterior tibial
and dorsalis pedis pulses 2+ regular, even bilaterally. Capillary
refill brisk, <3 seconds bilaterally. Full ROM of hips, knees,
ankles and toes bilaterally. No crepitation, erythemia, edema
bilaterally.

Upper Neurological:
Pinprick, light touch, vibration and position intact.
Stereognosis: able to identify. Graphesthesia: able to identify
number/letter. Rapid alternating movement (or finger to nose)
intact. Deep tendon reflexes 2+ and equal bilaterally.
Lower Neurological:
Pinprick, light touch, vibration and position intact. Negative
Rombergs test. Negative Babinski sign. Deep tendon reflexes
2+ and equal bilaterally.
Neuro / Muscular:
No atrophy, weakness, tremors or crepitus. Gait smooth and
coordinated. Able to tandem walk. Full range of motion of
spine.
Summary:
Questions:
Assessment:
Knowledge deficit r/t self-breast exam
Plan:
Follow-up in 1 week
Patient education completed on ___________, patient
verbalized understanding