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Comprehensive Medical Training Guide: Mastering S.O.A.P. Assessments at UCLA

This guide provides an in-depth overview of the S.O.A.P. (Subjective, Objective, Assessment, Plan) format used in clinical training at UCLA. It covers essential components of patient assessment, including obtaining patient information, analyzing vital signs, and documenting the history of present illness. The guide also discusses physical examination techniques, differential diagnoses, and treatment planning. Designed for medical students and professionals, this resource emphasizes thorough patient evaluation and effective communication within healthcare settings.

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Comprehensive Medical Training Guide: Mastering S.O.A.P. Assessments at UCLA

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  1. Global Medical Training at UCLA TJ & Poorva S.O.A.P.

  2. S.O.A.P. • SUBJECTIVE • OBJECTIVE • ASSESSMENT • PLAN

  3. SUBJECTIVE: PATIENT INFO • First, introduce yourself! • Obtain basic info • Past medical history (PMH) • Social life • Chief complaint (secondary complaint) • Vitals (objective) • Temperature • Pulse Rate • Blood Pressure

  4. SUBJECTIVE: PRESENT ILLNESS • History of present illness (HPI): • Onset • Location • Duration • Characteristics • Aggravating factors • Relieving factors • Severity

  5. SUBJECTIVE: Checklist of systems • Cont • Visual • Ears, Nose, Throat • Cardiology • Pulmonary • Gastrointestinal (GI) • Endocrine • Muscular • Dermatology • Neurology • Hematology • Psychology

  6. OBJECTIVE: PHYSICAL EXAM • Inspection/Observation • General, eyes, ears/nose/throat (ENT), cardiovascular (CV), respiratory, gastrointestinal, muscular, skin, neurology, psychology • Auscultation • Palpation • Percussion

  7. ASSESSMENT/PLAN • Discussion of case • Assessment • Preliminary diagnosis presented to attending physicians • Plan/Treatment • Prescribe medication • PREVENTATIVE ADVICE! • Rx • Doctor’s prescription

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