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Congestive Heart Failure
Systolic Murmur
Diastolic Murmur
Atrial fibrillation
Pericarditis
Chapter 3. Gastroenterology
Epigastric Pain
Cirrhosis
Diarrhea
Chapter 4. Nephrology
Nephrotic Syndrome
Hematuria
Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Chapter 5. Hematology/Oncology
Anemia
Thrombocytopenia
Polycythemia
Coagulopathy
Lymphoma
Leukemia
Breast Cancer
Lung Cancer
Colon Cancer
Prostate Cancer
Cellulitis
Chapter 7. Endocrinology
Diabetes
Hypothyroidism
Hyperthyroidism
Hyperparathyroidism
Adrenal Insufficiency
Cushing Syndrome
Osteoporosis
Dyslipidemia
Chapter 8. Rheumatology
Low-back Pain
Polyarthritis
Gout
Rheumatoid Arthritis
Seronegative Spondyloarthropathies
Inflammatory Myopathies
Vasculitis
Systemic Sclerosis
Chapter 9. Toxicology
Section 2. Pediatrics
Newborn Exam
Birth Trauma
Short Stature
Nosebleeds
Acne
Anaphylaxis
Seizure
Syncope
Chest Pain
Bloody Diarrhea—Colitis
Chemical Ingestions
Foreign Body
Edema—Nephrotic Syndrome
Henoch-Schönlein Purpura
Head Trauma
Limb Trauma
Inpatient Care
Pain Control
Initial Visit
Anemia
Antiphospholipid Syndrome
Chronic Hypertension
Hyperthyroidism
Isoimmunization
Mild Preeclampsia
Severe Preeclampsia
Twin Gestation
Term Labor
Chorioamnionitis
Labor Dystocia
Preterm Labor
Pyelonephritis
Rupture of Membranes
Postpartum Day 1
Postpartum Day 2
Dyspnea
Postpartum Fever
Postpartum Hemorrhage
Well-Woman Exam
Breast Mass
Dysmenorrhea
Family Planning—Sterilization
Galactorrhea
Hirsutism
Infertility
Menopause
Perimenopause
Premenstrual Syndrome
Secondary Amenorrhea
Urinary Incontinence
Vulvovaginitis
Pelvic Mass
Aortic Dissection
Cardiac Arrest
Endocarditis
Hypertensive Crisis
Myocardial Infarction
Palpitations
Syncope
Unstable Angina
Venous Thrombosis
Pneumothorax
Pulmonary Edema
Pulmonary Embolism
Appendicitis
Bowel Obstruction
Biliary Disease
Diverticulitis
Foreign-Body Ingestion
Gastrointestinal Bleeding
Hepatitis
Ischemic Bowel
Pancreatitis
Epididymitis
Hernia
Hydrocele/Varicocele
Kidney Stones/Nephrolithiasis
Pyelonephritis/UTI
Rhabdomyolysis
Testicular Torsion
Headache
Meningitis
Seizures
Stroke
Vertigo
Weakness
Chapter 24. Trauma
Animal Bite
Ankle Sprain
Burns
Fracture
Head Injury
Laceration
Section 5. Psychiatry
Appendix A
Index
Acknowledgments
I would like to thank all of the SOAP authors for their hard work and commitment to making
this series a success. I would also like to express special appreciation to Matt Hauber, Julie
Kostelnik, and Andrea Vosburgh at Wolters Kluwer for their patience and persistence in
keeping this project on track.
Contributors
Like most medical students, I started my ward experience head down and running, eager to
finally make contact with real patients. What I found was a confusing world, completely
different from anything I had known during the first 2 years of medical school. New
language, foreign abbreviations, and residents too busy to set my bearings straight: Where
would I begin?
Pocket textbooks, offering medical knowledge in a convenient and portable package, seemed
to be the logical solution. Unfortunately, I found myself spending valuable time sifting
through large amounts of text, often not finding the answer to my question, and in the
process missing out on teaching points during rounds!
I designed the SOAP series to provide medical students and house staff with pocket manuals
that truly serve their intended purpose: quick accessibility to the most practical clinical
information in a user-friendly format. At the inception of this project, I envisioned all of the
benefits the SOAP format would bring to the reader:
Learning through this model reinforces a thought process that is already familiar to
students and residents, facilitating easier long-term retention.
SOAP promotes good communication between physicians and facilitates the
teaching/learning process.
SOAP puts the emphasis back on the patient’s clinical problem and not the diagnosis.
In the age of managed care, SOAP meets the challenge of providing efficiency while
maintaining quality.
As sound medical-legal practice gains attention in physician training, SOAP
emphasizes adherence to a documentation style that leaves little room for potential
misinterpretation.
Rather than attempting to summarize the contents of a 1,000-page textbook into a miniature
form, the SOAP series focuses exclusively on guidance through patient encounters. In a
typical use, “finding out where to start” or “refreshing your memory” with SOAP books
should be possible in less than a minute. Subjects are always confined to 2 pages, and the
most important points have been highlighted. Topics have been limited to those problems
you will most commonly encounter repeatedly during your training, and contents are
grouped according to the hospital or clinic setting. Facts and figures that are not particularly
helpful to surviving life on the wards, such as demographics, pathophysiology, and busy
tables and graphs, have purposely been omitted (such details are much better studied in a
quiet environment using large and comprehensive texts).
Congratulations on your achievements thus far, and I wish you a highly successful medical
career!
Peter S. Uzelac, MD, FACOG, HCLD (ABB)
Abbreviations
Ca calcium
CA cancer
CA125 cancer antigen 125 test
CABG coronary artery bypass graft
CAD coronary artery disease
CAH congenital adrenal hyperplasia
C-ANCA cytoplasmic antineutrophil cytoplasmic antibodies
CAP community-acquired pneumonia
CBC complete blood count
CBC w/ diff complete blood count with differential
CBT cognitive behavioral therapy
cc cubic centimeter
C/C/E cyanosis/clubbing/edema
Chem 7 sodium, potassium, chloride, bicarb, BUN, creatinine, glucose
CHF congestive heart failure
Chol cholesterol
CHOP cyclophosphamide, hydroxydoxorubicin, vincristine (Oncovin),
prednisone
CHTN chronic hypertension
ciTBI clinically important traumatic brain injury
CK creatinine kinase
CLL chronic lymphocytic leukemia
CML chronic myeloid leukemia
CMP comprehensive metabolic panel
CMT cervical motion tenderness
CMV cytomegalovirus
CN cranial nerves
CNS central nervous system
COPD chronic obstructive pulmonary disease
CP chest pain; cerebral palsy
CPDD calcium pyrophosphate deposition disease
CPP cerebral perfusion pressure; chronic pelvic pain
CPR cardiopulmonary resuscitation
Cr creatinine
CRF chronic renal failure
CRP c-reactive protein
C-section; C/S cesarean section
CSF cerebrospinal fluid
CST contraction stress test
CT computed tomography, Chlamydia trachomatis
CTA clear to auscultation
CV cardiovascular
CVA costovertebral angle, cerebrovascular accident
PS pain score
PSA prostate-specific antigen
PSH past surgical history
pt patient
PT prothrombin time, physical therapy
PTB preterm birth
PTH parathyroid hormone
PTL preterm labor
PTSD posttraumatic stress disorder
PTT partial thromboplastin time
PTU propylthiouracil
PTX pneumothorax
PUBS percutaneous umbilical blood sampling
PUD peptic ulcer disease
Pulse ox pulse oximeter
PVC premature ventricular contraction
q quodque (every)
qd quaque die (once daily)
qh quaque hora (every hour)
qhs at bedtime
qid quater in die (four times daily)
R right, respirations
RA rheumatoid arthritis
RBC red blood cell
RDA recommended daily allowance
RDS respiratory distress syndrome
RDW red cell distribution width
Rec recommended regimen
Resp respiratory
RF rheumatic fever, rheumatoid factor
Rh Rhesus factor
RI reticulocyte index
RLQ right lower quadrant
RLS restless leg syndrome
ROM range of motion; rupture of membranes
ROS review of systems
RPL recurrent pregnancy loss
RPR rapid plasma reagin
RR respiratory rate
RRR regular rate and rhythm
RSV respiratory syncytial virus
RTA renal tubular acidosis
RUQ right upper quadrant