フィジカルアセスメント教科書紹介と、SOAPの例

フィジカルアセスメントの授業に関して、教科書については触れ忘れました。
今年使用したのはMosby's Guide to Physical Examinationという本で、900ページ以上ある分厚い本です。
かなり読み込みます。

AMAZONのページで、本をクリックすると中が閲覧できます。

フィジカルアセスメントの本では、これとBateの本が有名です。

医学生もこれらの本を使います。

フィジカルアセスメントの練習を医学生の友達としたことがあるので、学ぶ内容は同じだと思います。
History taking(患者の話を聞く練習)とSOAPの書き方はいやってほど叩き込まれます。(今年は私が叩き込む立場だったわけですが。)

さて、SOAPというのはご存知、カルテの基本的書き方です。ウェブを見ると、日本でも使われているようですね。
日本のsoap


S - subjective
O - objective
A - assessment
P - plan
にのっといて書いておきます。
中でも、S が細かく分かれていて、

CC Chief Complaint なにが問題なのか
HPI History of present illness その問題の経緯
PMH Past medical history 今までの病気
PSH Past surgical history 今までの手術
ALLERGY アレルギー(薬と、ラテックスと、ダイと、そのほかと)
MED Medications どんな薬を服用しているか
FH Family History 家族病歴
SH Social History アルコール、タバコ、ドラッグ、住居環境、仕事
Screening 予防注射歴、マモグラム、子宮頸癌検査、大腸検査など、誰もがしていなければいけない検査の記録
ROS Review of Systems 各器官において、ほかの症状がないかどうか

を聞き、書かねばなりません。

SOAPの例えを載せたいなーと思ったのですが、私のはすべて手書きで、クリニックにあるので、今日は載せられません。
代わりに、学生の一人が実習で介護ホームで患者さんを診たときのSOAPを下にコピぺします。
学生なので、かなり手のこんだ長い診察を1時間半かけてやっていました。
実際の診察ではこれよりも簡略です。
それでも、5分診療ということはないので(プライマリーケアではそんな短い診療は滅多にないと信じたい)、日本より長いSOAPかな?とは思いますが。

*******

V.V. 80yo W female w/ hypotension, HTN, CAD, COPD, CHF, S/P urethral polypectomy, Depression, Insomnia, Parkinson’s, Dehydration.
DOB: 12/04/28
Address: XXXXX Hamden, CT
Phone Number: XXXXXXX
Source: Patient. Somewhat reliable, oriented.

CC: C/o chest, abdominal and shoulder pain.

S: 96yo W female c/o a dull, aching, and sensation of aching/pressure 5/10 (scale 0-10) in her chest. Started on about a week ago hour after eating dinner. CP located in center of chest, radiating to L and R of chest and sometimes into her shoulder. Sx intermittent, lasting ~2 hours; Sx never on exertion; No relieving factors – spontaneously resolves without intervention; Reports nausea intermittently but no vomiting. Denies diaphoresis, dizziness, DOE, or edema; Denies Rx: (but pt’s chart notes she is being given Nitroquick for chest pain). No pain now in chest. Pt also c/o abdominal pain (6/10) when palpated. Notes that she has felt RUQ pain for the past year intermittently, sometimes when she eats, does not think it is related to her chest pain. She had her gallbladder removed about 15 yrs ago and the pain is localized in the area beneath her surgical scar. Pt fell from her wheelchair 1 wk ago onto her right shoulder and has had shoulder pain ever since. Pain is sharp, shooting and radiates from her shoulder down her arm. Takes Tylenol each night before bed but says this does nothing to relieve pain. Denies stress, anxiety, depression. Negative palpations, neg leg swelling. Denies SOB at rest, neg cough/ orthopnea. Positive for mild heartburn intermittently x past 2 yrs. No food sticking; no throat pain or difficulty swallowing; no blood in the stools or black colored stools. No N/V/F/C/D. No change in bowel habits. Negative lightheadedness. Denies headaches. Denies anxiety/depression/abuse.

PMH/GYN: G4P4004, LMP ??, pt does not remember her cycle history. Pt has a history positive for hypotension, HTN, MI, CAD, COPD, CHF, S/P urethral polypectomy, Depression, Insomnia, Parkinson’s, Dehydration. She has been DNR since 2007. Pt denies history of Cancer, Pulmonary dx, thyroid disorders. Pt has a PSH positive for hysterectomy, colonoscopy, angiogram, benign breast tumor removal. Dates unavailable. No complications noted.

Meds:
Levothyroxine 150mcg/d
Omeprazole 20mg/d
Metoprolol 25mg 2x/d
Mirtazapine 30mg/d
DSS Ducosate Sodium 100mg 2x/d
Nitroglycerin System 0.6mg patch
Nitroquick 0.4mg PRN for chest pain
Tylenol 650mg PRN for pain
Denies other OTCs, herbals, vitamins, eye/ear drops, inhalants, lotions, ointments.
Allergies: Valium, Morphine, PCN, VioXX, Prednisone, IVP dye, Tetracycline. Reactions not noted. Denies other allergies to environment, food, anesthesia, latex.

FMH:
Unknown. Pt does not remember and I was unable to obtain this from her chart.
Denies family history of Sudden Death, Aneurysm, Cancer, CAD.

SH: Pt worked as a secretary until 15 years ago. Widowed and has 4 children who visit her regularly. Denies feeling stressed (3/10) but states that she does not want to live in the nursing home and wishes she could live in her own home. Denies EtOH, tobacco, drugs.

Screening:
Last eye exam-unknown
Last pap smear-unknown
Last dental exam-unknown.
Unable to obtain results of past Mammograms, Colonoscopies or EKGs, but no abnormal results were found immediately in her chart.
Immunization: States she is current on vaccines. Recent Flu vaccine in 08.08.


O:

VS:
T= 97.4 F
B/P= R: 108/60 (lying)
HR 76 reg
RR 16 reg

General: Well-groomed, elderly W female. Oriented x4. No acute distress. Flat affect but willing to engage in conversation.

Head: Normocephalic, no lesions, lumps, scaling, parasites, or tenderness. Face symmetric, no weakness or involuntary movements.

Eyes: Acuity by Snellen chart OD 20/70, OS 20/70. Visual fields full, EOMs intact, no nystagmus. No ptosis, lid lag, d/c, or crusting. Corneal light reflex symmetric, no strabismus. Conjunctivae cloudy, positive cataracts. Sclera white, no lesions, redness. PERRLA. Negative red reflex. Unable to visualize optic cup or disc. Some vessels visible. No apparent pulsations or hemorrhages.

Ears: Pinna no masses, lesions, scaling, d/c, tenderness to palpation. Canals block 80% by cerumen. Whispered test negative. Weber test lateralizes equally. Rinne test: AC heard, negative bone conduction and = bilat.

Nose: Nares patent. No deformities or TTP. Mucosa pink, no lesions. Septum midline, no perforation. No maxillary or frontal sinus tenderness.

Mouth: Mucosa & gingival pink, no lesions or bleeding. Teeth are crooked. Most are discolored yellow/brown, none are loose. Tongue symmetric, protrudes midline, no tremor. Pharynx red with whitish exudates. Uvula rises midline on phonation. Gag reflex present. Tonsils present, pinkish color blends with the color of the pharynx.

Neck: Supple w/FROM. Symmetric, no masses, tenderness. No lymphadenopathy. Trachea midline. Thyroid nonpalpable, nontender. Jugular veins flat at 45 degrees. Carotid arteries 2+ and = bilat. No bruits.

Thorax and Lungs: AP/transverse diameter = 1/2. Chest expansion symmetric. Tactile fremitus = bilat. Lung fields resonant. Diaphragmatic excursion 5 cm and = bilat. CTA bilat. (+) Chest wall tenderness w/ palpation to 3rd and 4th LICS. No eccymosis.
Egophony, bronchophony, whispered petroliloquy: neg.

Heart: Precordium no abn pulsations, no heaves. PMI at 5th ICS MCL, 2.5 cm. No thrills, RRR: 76. S1 & S2 nl. No murmurs, bruits, gallops.

Abdomen: Rounded, soft, symmetric, non-distended. Skin smooth, no lesions, scars, striae. BS present x 4 quadrants, no bruits. Tympany in all quads. Liver span 7 cm at rt MCL. 2+ pulsations of aorta, renal, iliac, and femoral arteries. Spleen and kidneys non-palapble. Extreme tenderness noted in RUQ just below the breast. Pain is 6/10. No organomegaly, masses. No inguinal lymphadenopathy.

Genitalia: deferred.

Extremities: Color light pink. Redness, edema, and varicosities present on left leg. Scarring and lesions visible above left patella. Varicosities visible on all extremities. Pt has a bruise on right hand that spans the dorsal surface. No scars, no lesions on RLE, LUE, RUE. Calf tenderness and general tenderness of left leg when palpated. No calf tenderness, negative Homan’s sign, no clonus of RUE, LUE, RLE. Peripheral pulses present 2+ and equal bilaterally on upper extremities. Peripheral pulses non palpable on lower extremities.

Musculoskeletal: TMJ: positive slipping or crepitus. Vertebral column: no tenderness, deformity, curvature, has FROM. Upper extremities symmetric w/ limited ROM. Pt is unable to raise rt shoulder against resistance. Muscle strength: able to maintain flexion against with UEs (grade 3 with all musculature) but is unable to do so with LEs (0 for LLE and 1 for RLE). Pt is confined to a wheelchair and is unable to walk.

Neurological: Pt able to appropriately perform most of MMSE. Mental status: appearance, behavior, speech appropriate. A & O X 4. Thought incoherent but sensible. Remote memories intact, recent memories intact. CNs I through XII grossly intact. Sensory: pin prick, light touch, vibration intact on UEs, not intact on LEs. Motor: positive weakness, No tremors, no atrophy. Pt is unable to stand or walk on her own and only with the assistance of physical therapy. Cerebellar: finger to nose smooth and intact. DTRS of UEs intact, +2. Unable to assess DTRs of LEs.


A:

1. Age appropriate co-morbidities
2. Chest Pain
3. Unspecified Abdominal Pain
4. Shoulder pain s/p fall
5. Anxiety


P:
この学生は1年目なので、まだ「プラン」の部分は書いていません。

Signed,
______________, WHNP/ANP Student, 12/12/08

WHNP/ANPとは、Women's Health NP/ Adult NP と略です。

日本で書かれるカルテと比べてどうでしょうか。



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