Adolescent Sports Physical – Full SOAP

CC: [text name="variable_1" default="Sports Physical"]
Subjective
* HPI: [textarea name="variable_2" default="Patient X.X. is a XX-year-old male/female who is requiring a sports physical today for school. Patient will be starting ------. He/She appears relaxed, makes good eye contact and speaks clearly and easily."]
[textarea name="variable_3" default="*****Additional information here if needed*****"]
Allergies:[text name="variable_40" default="None."]
Medical History:[text name="variable_41" default="None."]
Hospitalizations:[text name="variable_42" default="None."]

* ROS
-Skin: [textarea name="variable_4" default="denies rashes or lesions; denies new nevi"]
-HEENT: [textarea name="variable_5" default="Head: denies migraines/headaches; Eyes: no corrective lenses or glasses. Ears: denies difficulty with hearing; denies tinnitus or vertigo. Nose/Sinuses: denies nasal congestion, sinus pressure/pain, and epistaxis. Teeth: denies issues"]
-Neck/Throat: [textarea name="variable_6" default="denies pain, lumps, or lymphadenopathy "]
-Cardiovascular: [textarea name="variable_7" default="denies chest pain, palpitations, or tachycardia. "]
-Respiratory: [textarea name="variable_8" default="denies cough, congestion, wheezing, or dyspnea"]
-Gastrointestinal: [textarea name="variable_9" default="denies abdominal discomfort, heartburn, reflux; reports regular voids and stools w/no issues"]
-Genitourinary: [textarea name="variable_10" default="denies any problems"]
-Musculoskeletal: [textarea name="variable_11" default="denies joint stiffness, joint pain or swelling"]
-Integumentary/Breast: [textarea name="variable_12" default="denies rash, pain, or masses"]
-Neurological: [textarea name="variable_13" default="denies seizures, sensory loss, headaches, migraines, or lethargy"]
-Hematologic/Lymphatic: [textarea name="variable_14" default="denies bruising, bleeding, and lymphadenopathy generally"]
-Endocrine: [textarea name="variable_15" default="no reported hair loss; skin is warm and dry; no night sweats reported "]
-Psychiatric: [textarea name="variable_16" default="denies anxiety and depression."]

Objective
* Vitals: HR [text name="variable_17" default=" "], RR [text name="variable_18" default=" "], Wt [text name="variable_19" default=" lb ( % percentile)"], Ht[text name="variable_20" default=" "], BMI [text name="variable_21" default=" "], BP [text name="variable_22" default=" "], Spo2 [text name="variable_23" default=" % "]

* Physical Exam
GENERAL: [textarea name="variable_24" default=" The patient is well developed, well nourished, alert and cooperative and appears to be in no acute distress. Vital signs as noted."]
EYES: [textarea name="variable_25" default="Normal eye and funduscopic exam."]
VISION SCREEN: [textarea name="variable_26" default="right eye 20/20, left eye 20/20"]
EAR, NOSE, AND THROAT: [textarea name="variable_27" default="Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose revels no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate, or lesion. Lips, teeth, and gums are in good general condition."]
NECK: [textarea name="variable_28" default="No thyromegaly."]
LYMPH: [textarea name="variable_29" default="No adenopathy."]
RESPIRATORY: [textarea name="variable_30" default="Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub diminished breath sounds, or labored breathing."]
HEART: [textarea name="variable_31" default="Regular rhythm with no significant murmurs, rubs, gallops, or clicks."]
ABDOMEN: [textarea name="variable_32" default="Abdomen is soft, nontender without masses, hepatosplenomegaly, or abnormal pulsation. There is no guarding or tenderness."]
GENITALIA: [textarea name="variable_33" default="Deferred - no issues. *****No signs of swelling or herniation; age appropriate external genitalia"]
MUSCULOSKELETAL: [textarea name="variable_34" default="Examination shows no significant weakness or deformity of the musculoskeletal system. Can perform duck walk and heel-toe walk."]
SKIN: [textarea name="variable_35" default="Normal, without rash or lesion."]

* Labs: [text name="variable_36" default="None."]
* Diagnostics: [text name="variable_37" default="None."]

PREVENTATIVE HEALTH
* Immunizations [text name="variable_43" default="UTD."]

ASSESSMENT/PLAN
[textarea name="variable_38" default="Z02.5 - ENCOUNTER FOR EXAMINATION FOR PARTICIPATION IN SPORT * Sports physical performed: patient is cleared to perform in school sports."]Follow-up: [text name="variable_39" default="routine annual"]