Complete Note
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 0 views in the 30 days since they brought the rhombus in for questioning.
[checkbox name="historian" value="new patient|existing patient||history provided by patient|history provided by family member||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]

HPI/SYMPTOMS: [checkbox name="hpi" value="new problem|chronic condition|acute exacerbation of chronic condition||started today|started yesterday|started several days ago|started more than 1 week ago|started months ago|started years ago|unsure||still present|increasing in severity|persisting|occasional|decreasing|resolved||affected by medication|affected by exertion|affected by pressure|affected by position/movement|affected by voiding|worse at night||as in cc|"][textarea cols=50 rows=3]

MEDICATIONS: allergies reviewed, [checkbox name="medications" value="taking OTC|taking RX||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages|unable to name medications/reasons/dosages||medication list/labels/containers available for review|medication list/labels/containers not available for review||none reported|"][textarea cols=50 rows=3]

PERTINENT MEDICAL HISTORY: [checkbox name="recent" value="stress|travel|new sexual partner||PCP/UC/ER visit|hospitalization/surgery/procedure||new medications|antibiotic use|recent diagnostic study||frequent UTIs|frequent vaginosis|kidney stones|incontinence||ovarian cyst|endometriosis|fibroids|multiple pregnancies||DM|immunosuppression||noncontributory|none reported|"][textarea cols=50 rows=3]

Urinary: [checkbox name="urinary_cc" value="burning|frequency|pain with urination|blood in urine|back pain||stress incontinence|urge incontinence||no sx reported|"][textarea cols=50 rows=3]
Vaginal: [checkbox name="vaginal_cc" value="odor|clear discharge|yellow discharge|brown discharge||itching|skin lesions||painful intercourse|postcoital bleeding||vaginal bleeding|vaginal clots|vaginal tissue||no sx reported|"][textarea cols=50 rows=3]
Menstrual: [checkbox name="menstrual_cc" value="regular|irregular|heavy|painful|spotting|missed|postmenopausal|"][textarea cols=50 rows=3]
LMP: [textarea cols=40 rows=1 default="not reported/NA"]
Sexual: [checkbox name="sexual_cc" value="active|inactive|one partner|multiple partners|new partner||oral|vaginal|anal|"][textarea cols=50 rows=3]
Last intercourse: [checkbox name="last_intercouse" value="yesterday|several days ago|one week ago|weeks ago|months ago||protected|unprotected|"][textarea cols=40 rows=1 default="not reported/NA"]
Birth Control: [checkbox name="birth_control" value="BCP|Depo|implant|IUD|BTL|condoms||none|"][textarea cols=40 rows=1 default="not reported/NA"]
GI: [checkbox name="abdominal_cc" value="upper abd pain|lower abd pain|diarrhea|constipation|nausea/vomiting||no sx reported|"][textarea cols=50 rows=3]



REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="constitutional_symptoms" value="fever|night sweats|hot flashes|unintentional wt loss"]
HEAD/FACE: [textarea cols=40 rows=1]
[checklist name="head_symptoms" value="headache|scalp swelling|trauma|facial numbness"]
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|halos|dryness|redness|discharge"]
EARS: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|pressure|discharge|wax|hearing loss|ringing"]
NOSE: [textarea cols=40 rows=1]
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache|jaw pain/clicking|changes in taste"]
THROAT: [textarea cols=40 rows=1]
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness|globus"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheadedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="myalgias|pain|chronic pain/meds"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|speech difficulty|tremor|seizures|urinary/bowel changes|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|withdrawal|depression|apathy|anxiety|mood swings|memory loss|insomnia"]
ENDO: [textarea cols=40 rows=1]
[checklist name="endo_symptoms" value="cold intolerance|skin dryness|hair loss"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=40 rows=1]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"]


UA: [checkbox name="office_ua" value="non-specific changes|normal|suggestive of UTI||leukocytes|nitrites|glucose|blood|declined||urine cx sent out|"][textarea cols=50 rows=3]
hcg: [checkbox name="office_hcg" value="N/A||positive home test||negative clinic test|positive clinic test|declined|"][textarea cols=50 rows=1]
OUTSIDE DIAGNOSTIC & LABORATORY RESULTS: [checkbox name="new_labs" value="normal|non-specific changes|no acute findings||discussed with patient/SO||no new results|"][textarea cols=50 rows=3]
General: [checkbox name="appearance" value="well-appearing||normal built|heavy built|lean|well-nourished|emaciated|frail||no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating & getting on/off exam table|ill-appearing|tired-looking|short of breath|diaphoretic||good hygiene|disheveled|bizarre clothes|body odor||drowsy|appears impaired|slumped||no ambulation aids/DME|ambulation requires walker|ambulation requires cane|ambulation requires wheelchair||wearing cervical collar|wearing lumbar support|wearing extremity brace|"][textarea cols=50 rows=2]
Head/Face: [checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][textarea cols=50 rows=2]
Eyes: [checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear||glasses|contacts|conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=50 rows=2]
Ears: [checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or discharge|TMs normal in appearance|"][textarea cols=50 rows=2]
Nose: [checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||swollen & boggy mucosa|mucosal congestion|clear discharge|yellow discharge|crusty discharge|rhinophyma|"][textarea cols=50 rows=2]
Mouth: [checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||upper denture|lower denture||poor dentition|oral ulcers|gum swelling|tooth decay|"][textarea cols=50 rows=2]
Throat: [checkbox name="throat" value="normal voice, no stridor|patent pharynx w/o swelling or exudates|uvula midline||hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal erythema w/o exudates|"][textarea cols=50 rows=2]
Neck: [checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD||anterior LAD|posterior LAD||thyroid enlargement|nuchal tenderness|"][textarea cols=50 rows=2]
Chest/Lungs: [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=50 rows=2]
CV: [checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=50 rows=2]
Abdomen: [checkbox name="abd" value="normal visual inspection, no distension|normal active bowel sounds|soft non-tender|no bruit auscultated over AA and renal arteries||protruding|surgical scar|umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|colostomy in situ||deferred|"][textarea cols=50 rows=2]
MSK: [checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for patient’s age||non-tender C-spine with good ROM|non-tender L-spine with good ROM||strength, tone, & bulk symmetrical & grossly intact||kyphosis|paraspinal muscle spasm|C-spine tenderness & DROM|neck pain with active motion|paracervical muscle spasm|old surgical scar(s) in C-spine|trapezius tenderness||L-spine tenderness|reduced painful ROM in lumbar region|paraspinal muscle spasm|trigger points in L-spine|old surgical scar(s) in L-spine||heel-walk & toe-walk without difficulty|negative seated SLR|positive seated SLR|"][textarea cols=50 rows=2]
Skin: [checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||tattoos|body piercings|poor turgor||dry|sweaty|"][textarea cols=50 rows=2]
Neuro: [checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|ambulates w/o limp or alteration in gait||extremities strong w/o atrophy|no gross motor deficits|sensation symmetrical & grossly intact||no involuntary movements or tremor||antalgic gait|wide gait|shuffling gait||diffuse numbness w/o dermatomal pattern|dystonia|tardive dyskinesia|tics|"][textarea cols=50 rows=2]
Speech/Vocalization: [checkbox name="speech" value="normal for age|clear & coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive|argumentative|cursing, swearing|previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks|"][textarea cols=50 rows=2]
Behavior/Psychomotor Activity: [checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history & exam||guarded|anxious|irritable|frustrated|labile||agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles||grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=2]
GU/Pelvic: [checkbox name="gu" value="no suprapubic tenderness|no CVAT bilaterally||s/p tenderness|CVAT||normal external genitalia|no inguinal LAD||declined|"][textarea cols=70 rows=1]



Discussion: [textarea cols=50 rows=5]

[comment memo="DX:
abdominal pain
cervicitis
dysfunctional uterine bleeding
herpes genitalis
incontinence of urine
menopause
ovarian cyst
pelvic pain
pid
pyelonephritis
ureterolithiasis
urinary tract infection
vaginal bleeding
vaginosis"]


.
PLAN OF CARE: patient/family verbalized understanding of dx & POC, [checkbox name="discussed" value="agreed with dx & POC|did not agree with dx & POC – encouraged to seek second opinion|"][textarea cols=50 rows=3]
ORDERS - MA: [checkbox name="order_MA" value="injection|Rocephin 1 gm IM now|none|"][textarea cols=50 rows=3]
ORDERS - RX: [checkbox name="order_RX" value="OTC|ABX|Pyridium 100 mg TID #6|Rx for suspected vaginosis|Rx for suspected STI||electronic|paper|given to MA to be transmitted to pharmacy||none|"][textarea cols=50 rows=1]
[textarea cols=50 rows=1]
ORDERS - LABS: [checkbox name="order_lab" value="CBC|CMP|TSH|A1C||UA|urine cx|vaginosis swab|STI||none|"][textarea cols=50 rows=3]
ORDERS - IMAGING: [checkbox name="order_imaging" value="X-ray|US|MRI||none|"][textarea cols=50 rows=2]
ORDERS - REFERRALS: [checkbox name="order_refer" value="local pharmacy to verify vaccination status and administer vaccines, if indicated||deferred||none|"][textarea cols=50 rows=3]
ORDERS - FORMS: [checkbox name="forms" value="excuse|accomodations|clearance|return to school/work|school/participation physical||none|"][textarea cols=50 rows=3]
REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, [checkbox name="instructions" value="medications|PMP|previous visits|laboratory/diagnostic studies||hydration and not holding urine in|appropriate follow up|medication compliance|"][textarea cols=50 rows=3]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged|appears well|non-toxic|physical exam unremarkable for any emergent condition||no safety concerns at this time|safety concerns d/t depressed agitated mood|safety concerns d/t impulsiveness|safety concerns d/t hostile temper|safety concerns d/t past attempts|safety concerns d/t current suicidal verbalization|"][textarea cols=50 rows=1]
DISPOSITION: [checkbox name="disposition" value="home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer||left exam room before visit conclusion|was asked to leave clinic|"][textarea cols=50 rows=3]
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, [checkbox name="next" value="f/u here|in-person|televisit|f/u w PCP||RTC 24 hours|RTC 2-3 days|RTC 1 week||RTC 30 days|RTC 6 weeks|RTC 3 months|RTC 6 months|RTC 12 months||f/u acute episode|f/u labs|f/u imaging|f/u med change/new|"][textarea cols=50 rows=3]
BARRIERS TO CARE: [checkbox name="barriers" value="incomplete history|poor cooperation with exam|language barrier|affect|socio-cultural factors||vague shifting complaints|history not supported by objective findings|supporting documentation unavailable|poor compliance with POC||intolerance of/therapeutic failure on multiple meds|negative attitude to diagnostic impression & proposed tx|lack of interest in nonpharmacologic therapies||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others||hostile/disruptive behavior||none noted at this time|"][textarea cols=50 rows=3]


HPI/SYMPTOMS:

MEDICATIONS: allergies reviewed,

PERTINENT MEDICAL HISTORY:

Urinary:
Vaginal:
Menstrual:
LMP:
Sexual:
Last intercourse:
Birth Control:
GI:



REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

HEAD/FACE:

EYES:

EARS:

NOSE:

MOUTH:

THROAT:

NECK:

CV:

CHEST/RESPIRATORY:

MSK:

NEURO:

PSYCH:

ENDO:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:



UA:
hcg:
OUTSIDE DIAGNOSTIC & LABORATORY RESULTS:
General:
Head/Face:
Eyes:
Ears:
Nose:
Mouth:
Throat:
Neck:
Chest/Lungs:
CV:
Abdomen:
MSK:
Skin:
Neuro:
Speech/Vocalization:
Behavior/Psychomotor Activity:
GU/Pelvic:



Discussion:

DX:
abdominal pain
cervicitis
dysfunctional uterine bleeding
herpes genitalis
incontinence of urine
menopause
ovarian cyst
pelvic pain
pid
pyelonephritis
ureterolithiasis
urinary tract infection
vaginal bleeding
vaginosis



.
PLAN OF CARE: patient/family verbalized understanding of dx & POC,
ORDERS - MA:
ORDERS - RX:

ORDERS - LABS:
ORDERS - IMAGING:
ORDERS - REFERRALS:
ORDERS - FORMS:
REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services,
DISCHARGE CONDITION/SAFETY:
DISPOSITION:
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx,
BARRIERS TO CARE:

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: