PSOAP
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ScribdTranslationsPSOAP
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ScribdTranslationsPsignificaPaciente, the patient's age, gender, and diagnosis should be described.
systemic (if any), the specific diagnosis(es) and treatment(s).
Subjective signifies, it should describe what the patient refers to regarding
symptomatology.
OmeansGoal, it should describe what the student operator observes regarding
to the patient.
Attention, the procedure or procedures performed must be described.
P means Treatment Plan.
Example:
P: 30-year-old female patient who comes to an outpatient consultation due to presenting the
the following urological symptoms:
Dysuria, frequency and urgency of urination.
fever.
Patient reports onset of symptoms three days ago with the appearance of urgency and
urinary frequency, on the first day she reports having 8 urinations, on the second 12 and 3 on
this day. If accompanied by dysuria, the pain is burning, it occurs only when urinating and
disappears immediately after finishing urination. In addition to fever on the day of
today of 38.5. Has not received any treatment. As for family history of
importance of deceased mother due to type 2 diabetes, unknown health history of the lineage
parental as well as the causes of death. Allergies, poisoning, trauma, and
transfusions.
T/A: 130/90, FR 21 per minute, FC 85 per minute, temperature 38.5°C, female patient
with an apparent age matching the chronological age, calm, oriented in the three spheres, cooperative,
medium constitution, bodily integrity, freely chosen attitude.
On physical examination: Normocephalic skull, without exostosis or depressions. Cylindrical neck.
Normal thorax, symmetrical. Normal chest expansion and contraction. No crepitations or sounds.
rhythmic and good intensity heartbeats. Abdomen with normal umbilical scar. To the
Ausculation shows normal peristalsis. On palpation, soft and depressible, it manifests
pain in the suprapubic area with deep palpation, no visceromegaly is found.
Thoracic and pelvic extremities intact and functional. Upon examination of the genitals,
skin without lesions, presence of pubic hair, labia majora of size and coloration
Normal, vaginal introitus is observed. No discharge is noted.
A: 30-year-old female patient with probable lower urinary tract infection.
laboratories: request EGO whose sample must be taken midstream and urine culture
Therapeutic plan:
Start with trimethoprim-sulfamethoxazole 80/400mg every 12 hours for 7 days. Paracetamol
250mg every 6 hours.
Increase fluid intake and maintain a proper diet.
