FULL SOAP NOTE V1

Date of Visit
[date name="variable_1" default="00/00/20--"]

Identifying Data: Age:[text name="Value_Generic" size="5"] Gender: [select name="variable_1" value="Male|Female"] Race:[select name="variable_1" value="Asian|Caucasian|Black|Hispanic|Native American|Other"]

Medical History: [textarea cols=80 rows=1 default="insert "]
Surgical History: [textarea cols=80 rows=1 default="insert "]
Family History: [textarea cols=80 rows=1 default="insert "]
Social History: [textarea cols=80 rows=1 default="Occupation:   Living situation:   Tobacco:   Alcohol Consumption:   Ilicit drugs:   "]
Allergies: [textarea cols=80 rows=1 default="insert "]
Medication: [textarea cols=80 rows=1 default="insert "]

====================== SUBJECTIVE ====================================

REVIEW OF SYSTEMS:
General:
[checklist name="General" value="fever|fatigue|night sweats|change in appetite|change in weight"]
Skin:
[checklist name="Skin" value="rash|itching|change in hair/nails"]
Head:
[checklist name="Head" value="headache|head injury"]
Eyes:
[checklist name="Eyes" value="change in vision|eye pain|double vision|flashing lights|corrective lenses"]
Ears:
[checklist name="Ears" value="change in hearing|ear pain|discharge|ringing|dizziness"]
Nose/Sinus:
[checklist name="NoseSinus" value="nose bleeds|congestion|frequent colds|sinus infections"]
Allergies:
[checklist name="Allergies" value="hives|swelling of lips/tongue|hay fever|asthma|eczema|sensitivity to drugs, foods, pollens, or dander"]
Mouth/Throat:
[checklist name="MouthThroat" value="bleeding gums|sore throat|sore tongue|pain in mouth|sores in mouth|hoarseness"]
Neck:
[checklist name="Neck" value="lumps|swollen glands|goiter|stiffness"]
Breast:
[checklist name="Breast" value="lumps|pain|nipple discharge"]
Cardio:
[checklist name="Cardio" value="chest pain|palpitations|heart murmur|history of heart medications|rheumatic heart disease|high blood pressure|high cholesterol|change in color of fingers or toes|swelling in hands or feet"]
Pulmonology:
[checklist name="Pulm" value="shortness of breath|cough|production of phlegm|coughing up blood|bronchitis|emphysema|COPD"]
GI:
[checklist name="GI" value="problems swallowing|heartburn|nausea|vomiting|diarrhea|constipation|change in bowel habits|abdominal pain|excessive belching|excessing flatus|food intolerance|rectal bleeding|hemorrhoids|yellowing of skin"]
Urinary:
[checklist name="Urinary" value="difficulty in urination|pain or burning with urination|frequent urination at night|urgent need to urinate|incontinence of urine|dribbling|decreased urine stream|blood in urine|UTI|stones|prostate issues"]
Peripheral Vascular:
[checklist name="PeripheralVascular" value="leg cramps|varicose veins|clots in veins"]
Musculoskeletal:
[checklist name="MSK" value="pain|swelling|stiffness|decreased range of motion|broken bone|serious sprains|arthritis|gout"]
Neurologic
[checklist name="Neuro" value="headaches|migraines|seizures|loss of consciousness/fainting|paralysis|weakness|muscle spasm|tremor|involuntary movement|incoordination|numbness|feeling of pins and needles or tingles"]
Hematologic:
[checklist name="Heme" value="anemia|easy bruising|easy bleeding|past transfusions"]
Endocrine:
[checklist name="Endo" value="abnormal growth|increased thirst|increased urine production|thyroid issues|heat/cold intolerance|excessive sweating|diabetes"]
Psychiatric:
[checklist name="Psych" value="anxiety|muscle tension|depression|thoughts of suicide|self harm|thoughts of hurting others|memory issues|sleep issues|change in mood|pleasure in doing things|ADD/ADHD|past treatment with psychiatrist|other psychiatric diagnosis"]



Vital Signs: [textarea cols=80 rows=1 default="HR:   BP:   SPO2:   RR:   Temp:   HT:   WT:   BMI:  "]
===================== PHYSICAL EXAM 3 ================================

PE FINDINGS:
General:
[textarea name="variable_21" default="Insert abnormalities or delete this text to remove."] [checkbox name="GeneralPE" value="A&Ox4. |Does not appear to be in any acute distress. |Well-groomed. |Appears stated age."]

Neuro:
[textarea name="variable_22" default="Insert abnormalities or delete this text to remove."] [checkbox name="NeuroPE" value="Normal motor function w/ muscle strength 5/5 b/l on UE and LE. |Sensation is intact b/l. |Memory is grossly intact. |Cerebral function and thought process intact. |No gait abnormalities observed. |Neuro exam not performed."]

Integumentary:
[textarea name="variable_23" default="Insert abnormalities or delete this text to remove."] [checkbox name="SkinPE" value="Skin is warm, dry, and intact.|No lesions.|No cyanosis or clubbing. |Integumentary exam not performed."]

HEENT:
[textarea name="variable_24" default="Insert abnormalities or delete this text to remove."] [checkbox name="HEENTPE" value="Head is normocephalic and atraumatic. |Head is w/o tenderness, visible or palpable masses, and depressions. |Hair is of normal texture and distribution. |EOM intact. |PERRLA. |Hearing is grossly intact. |TM is normal in appearance w/ normal landmarks and cone of light. |Nasal mucosa is pink and moist. |Oral mucosa is pink and moist w/ good dentition. |Pharynx is normal in appearance w/o tonsillar swelling or exudates. |Neck is supple w/o any lymphadenopathy. |Trachea is midline. |Thyroid gland is normal w/o any palpable masses. |Carotid pulse 2+ b/l w/o bruit. |No JVD. |HEENT exam not performed."]

Cardiopulmonary:
[textarea name="variable_25" default="Insert abnormalities or delete this text to remove."] [checkbox name="CardpulmPE" value="Heart rate and rhythm are normal. |Normal S1 and S2. |No murmurs, gallops, rubs, or extra heart sounds appreciated upon auscultation. |Chest wall is symmetric and w/o deformity or signs of trauma. |No signs of respiratory distress. |Lungs CTA b/l w/o rales, ronchi, or wheezes. |Cardio exam not performed. |Pulmonary exam not performed."]

GI:
[textarea name="variable_26" default="Insert abnormalities or delete this text to remove."] [checkbox name="GIPE" value="Abdomen is soft, symmetric, and non-tender w/o distention. |No visible lesions or scars. |Aorta is midline w/o bruit or visible pulsation. |Umbilicus is midline w/o herniation. |Normal BS in all four quadrants. |No masses, hepatomegaly, or splenomegaly are noted. |Abdominal exam not performed."]

GU:
[textarea name="variable_27" default="Insert abnormalities or delete this text to remove."] [checkbox name="GUPE" value=" Normal rectal sphincter tone. |No external masses or lesions. |Stool is normal in appearance. |Guac negative. |External genitalia is normal in appearance w/o lesions, swelling, masses or tenderness. |Vagina is pink and moist w/o lesions or abnormal discharge. |Uterus is anteflexed, non-tender, and normal in size. |Ovaries are non-tender w/o palpable masses or enlargement. |Circumcised male. |Uncircumcised male. |Prepuce easily retracts. |No penile discharge or lesions. |No scrotal swelling or discoloration. |Testes descended b/l, smooth, no masses. |Epididymis nontender. |No inguinal or femoral hernias. |No GU exam performed. |No rectal exam performed."]

Peripheral Vascular/MSK:
[textarea name="variable_28" default="Insert abnormalities or delete this text to remove."] [checkbox name="PeriVascPE" value="UE and LE are atraumatic in appearance w/o tenderness or deformity. |No swelling or erythema. |Full ROM is noted in all joints. |Muscle strength is 5/5 b/l. |Tendon function is normal. |Cap refill is less than 3secs in all extremities. |Pulses palpable. |No peripheral vascular exam was performed. |No MSK exam was performed."]

Psych:
[textarea name="variable_29" default="Insert abnormalities or delete this text to remove."] [checkbox name="MSE" value="Appropriate mood and affect. |Adequate judgement and insight. |No visual or auditory hallucinations. |No SI or HI. |No parasuicidal thoughts or behavior. |MSE not performed."]

** EDUCATION ** EDUCATION ** EDUCATION ** EDUCATION ** EDUCATION **

[checkbox name="Education" value="Skin is warm, dry, and intact.|No lesions.|No cyanosis or clubbing. |Integumentary exam not performed."]


Diabetes
- Diet: Foods high in carbs: Grains – These include bread, pasta, rice, and cereal. Fruits and starchy vegetables – Starchy vegetables include potatoes, corn, and squash. Milk and other dairy products – Dairy products include cheese and yogurt. Foods with added sugar – These include sweets and baked goods likes cookies and cakes, as well as sugary drinks like juice and soda.It is best to get most of your carbs from fruits, vegetables, whole grains (like whole-wheat bread, whole-grain cereals, and brown rice), and low-fat milk and dairy products. Spread out your carbs over 4 to 6 small meals each day instead of 3 big ones. Substitute regular soda for diet soda. Use splenda, equal, sweet and low instead of regular granulated sugar. Low carb tortilla and bread can be substitute for regular tortilla and bread and can be bought at Albertsons, Walmart, Costco, Stater Bros. 
- Foot care: Patients with diabetes can have nerve damage called neuropathy which normally affects the feet and toes first. Symptoms include: Numbness or decreased sensation burning pain worst at rest or at night, and tingling. Wear shoes or slippers at all times and never go barefoot. Check feet daily for cuts, blisters, swelling, or redness. If you cannot see your feel use a mirror. Always check your shoes for any sharp objects. Seek medical care if there are any wounds or skin abnormalities to feet. Wash feet with arm water and soap daily and pat dry. Put moisturizing cream or lotion to the tops and bottoms of feet. Wear fitting shoes with dry socks. 
- Lifestyle changes: Eat fresh fruit, vegetables, whole grains, and low-fat dairy products. Limit amount of meat and fried or fatty foods. Exercise 30 minutes a day three times a week. Avoid drinking alcohol because it can increase blood sugar and blood pressure. 




** RESOURCES ** RESOURCES ** RESOURCES ** RESOURCES ** RESOURCES **
[link url="https://www.typhongroup.net/nsst/data/login.asp" memo="Typhon 3257/9022025953/CPR12#$"]

[link url="https://vle.phoenix.edu/ultra/course" memo="UOP Blackboard"]

[link url="https://fpnotebook.com/" memo="FP Book"]

[link url="https://www.epocrates.com/login?refernext=https://www.epocrates.com/account/profile" memo="Epocrates ALNRN/CPR5"]

[link url="https://next.amboss.com/us" memo="Amboss asripors/cy714"]

[link url="https://vle.phoenix.edu/ultra/course" memo="UOP Blackboard"]

[link url="https://med.ucf.edu/media/2018/08/Guide-to-the-Comprehensive-Adult-H-and-P-Write-up-2017-18.pdf" memo="Guide to the Comprehensive Adult H&P Write Up"]