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What are the 7 components of the S part of SOAP? - Answer- CC, HPI, FMHx, PMHx,
PSHx, SHx, ROS
What are the 8 elements of HPI? - Answer- context, onset, location, duration, severity,
modifying factors, associated S/Sx, quality
What are the components of the O part of SOAP? - Answer- PEx, MDM (orders/results
of labs/imaging, consult within dept, DDx)
What are the components of the P part of SOAP? - Answer- disposition (d/c, admit,
transfer), medications, outside tests, counseling, f/u with outside doctor
Common diseases/disorders of PMHx? - Answer- DM, dyslipidemia, HTN,
Hyperthyroidism
What are the components of SocHx? - Answer- tobacco use, alcohol, drug use,
exercise frequency
What are the components of an ROS? - Answer- constitutional, head, eyes, ENT,
respiratory, cardiovascular, musculoskeletal, skin, hematologic, GI, genitourinary,
neural, psych
What does an "all normal exam" for Constitutional look like? - Answer- WDWN, NAD
What does an "all normal exam" for Neck look like? - Answer- no JVD, no trachea
deviation, no thyromegaly
What does an "all normal exam" for Pulmonary look like? - Answer- regular RR, no
respiratory distress; lungs CTA
What does an "all normal exam" for Cardiovascular look like? - Answer- regular rate &
rhythm; no peripheral edema
What does an "all normal exam" for GI look like? - Answer- and soft & non-tender; no
rebound; no guarding, bowel sounds normal, no hepatosplenomegaly