Nina SOAP

Name: [text default="AGE + GENDER"] Pt. Encounter Number: [text default="AGE + GENDER"]
Date:[text default="AGE + GENDER"] Age:[text default="AGE + GENDER"] Sex:[text default="AGE + GENDER"]

SUBJECTIVE
CC:"[text default="AGE + GENDER"]"

HPI:
The patient is a [text default="AGE + GENDER"] who presents to the the clinc complaining of [text default="CHIEF COMPLAINT"] that began [text default="ONSET"] while [text default="CONTEXT"]. Symptoms have been [text default="TIMING"] since onset and pt rates them as [text default="SEVERITY"] in severity. Patient reports the symptoms are located [text default="LOCATION"] and describes the quality as [text default="QUALITY"]. Symptoms associated with [text default="POSITIVE SYMPTOMS"] but denies any [text default="NEGATIVE SYMPTOMS"].

Symptoms are improved with [text default="MODIFYING FACTOR"] and exacerbated by [text default="MODIFYING FACTOR"]. Patient [text default="REPORTS/DENIES"] history of similar symptoms. Pertinent medical history includes [text default="PERTINENT PAST MEDICAL HISTORY"]. 
Patient adds [text default="OTHER DETAILS"].

 
Medications: [text default="AGE + GENDER"]
PMH: [text default="AGE + GENDER"]
Allergies: [text default="AGE + GENDER"]
Medication Intolerances: [text default="AGE + GENDER"]
Chronic Illnesses/Major traumas:
[text default="AGE + GENDER"]
Hospitalizations/Surgeries:
[text default="AGE + GENDER"]

Social History

Patient reports [text name="" default="where pt live"] with [text name="" default="adequate?inadequate"] home conditions. [text name="" default="Confirms/denies"] history of smoking. [text name="" default="Confirms/denies"] history of alcohol use. [text name="" default="Confirms/denies"] use of illicit drug use. Exercise consists of [text name="" default=""]


Family History

Mother([text name="" default="age"])is ([text name="" default="condition/hx"]) and lives [text name="" default=""]. Father([text name="" default="age"]) is [text name="" default=" condition/hx"] and lives [text name="" default=""]. Patient has [text name="" default=""] siblings. [text name="" default="any add. info?"]

ROS

[checkbox name="variable_1" value="Per HPI"]


Constitutional/General:
 [select name="" value="c/o of|  "]  [checkbox name="1" value=" | fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]
denies [checkbox name="356" value=" | fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]

Head:
 [select name="" value="c/o of|  "]  [checkbox name="2" value=" |headaches|dizziness|syncope|dizziness|sinus pain|LOC"]. Denies [checkbox name="43" value=" |headaches|dizziness|syncope|dizziness|sinus pain|LOC"].

Eyes:
 [select name="" value="c/o of|  "]  [checkbox name="44" value=" |vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"]. Denies [checkbox name="4" value=" |vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].

Ears: 
[select name="" value="c/o of|  "]  [checkbox name="5" value=" |ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"] Denies [checkbox name="6" value=" |ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"].

Nose,Mouth, and Throat
 [select name="" value="c/o of|  "]  [checkbox name="7" value=" |loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"] Denies [checkbox name="8" value=" |loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"].
[select name="" value="c/o of|  "]  [checkbox name="9" value=" |hoarseness|change in voice B|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"] Denies [checkbox name="10" value=" |hoarseness|change in voice|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"]. 

Neck: 
[select name="" value="c/o of|  "]  [checkbox name="11" value=" |neck pain|stiffness|edema"] Denies [checkbox name="13" value=" |neck pain|stiffness|edema"] 

Cardiac: 
[select name="" value="c/o of|  "]  [checkbox name="15" value=" |chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"] . Denies [checkbox name="16" value=" |chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"].
[select name="" value="c/o of|  "]  [checkbox name="17" value=" |claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"] . Denies [checkbox name="18" value=" |claudication|color changes in extremities|parathesias|coldness in extremities"].

Respiratory:
 [select name="" value="c/o of|  "]  [checkbox name="19" value=" |Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"] . Denies [checkbox name="20" value=" |Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"].

Gastrointestinal: 
[select name="" value="c/o of|  "]  [checkbox name="21" value=" |appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] . Denies[checkbox name="22" value=" |appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] 

Endocrine: 
[select name="" value="c/o of|  "]  [checkbox name="23" value=" |thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"] . Denies [checkbox name="24" value=" |thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"].

Hematological/Lymphatic: 
[select name="" value="c/o of|  "]  [checkbox name="25" value=" |anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"] . Denies [checkbox name="26" value=" |anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"].

Genitourinary:
 [select name="" value="c/o of|  "]  [checkbox name="27" value=" |dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"] . Denies [checkbox name="28" value=" |dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]

Reproductive (female): 
[select name="" value="c/o of|  "]  [checkbox name="29" value=" |change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"] . Denies [checkbox name="30" value=" |change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]. Gravida  Para  Abortus . LMP: .

Reproductive (male): 
[select name="" value="c/o of|  "]  [checkbox name="31" value=" |difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"] . Denies [checkbox name="32" value=" |difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"].

Musculoskeletal: 
[select name="" value="c/o of|  "]  [checkbox name="33" value=" |joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"] . Denies [checkbox name="34" value=" |joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"].

Integument:
[select name="" value="c/o of|  "]  [checkbox name="35" value=" |pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"] . Denies [checkbox name="36" value=" |pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"].

Neurological:
 [select name="" value="c/o of|  "]  [checkbox name="37" value=" |change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"] . Denies [checkbox name="38" value=" |change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"].

Psychiatric: 
[select name="" value="c/o of|  "]  [checkbox name="39" value=" |depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"] . Denies [checkbox name="40" value=" |depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"]

Breasts: 
[select name="" value="c/o of|  "]  [checkbox name="41" value=" |breast pain/soreness|discharge|lumps"]
. Denies [checkbox name="42" value=" |breast pain/soreness|discharge|lumps"]

OBJECTIVE

Vital signs: T[text name="55" default="sample text"] P[text name="56" default="sample text"] R[text name="57" default="sample text"] BP[text name="58" default="sample text"] O2 Sat [text name="59" default="sample text"] on [text name="60" default="sample text"]

Nurtition: Weight: [text name="61" default="sample text"] BMI: [text name="62" default="sample text"] Weight changes: [text name="99" default="sample text"]

Appearance: [checkbox name="appearance" value="Well-appearing, well-nourished, NWOB|age-appropriate behavior||active, non-toxic|engages well|strong suck|crying|easily consoled||ill-appearing|tired-looking|diaphoretic|short of breath|sweating|cooperative with exam|poor cooperation with exam|agitated|anxious|appears sedated|appears impaired|disheveled|"] [textarea cols=40 rows=2]
DME: [checkbox name="dme" value="none|in wheelchair|ambulates effortlessly|ambulates w walker|ambulates w cane|wears cervical collar|wears lumbar support|wears brace|"] [textarea cols=40 rows=2]
Discomfort: [checkbox name="discomfort" value="no signs of discomfort visible while ambulating & getting on/off exam table|no signs of discomfort visible while sitting in chair||guarding|restlessness|sighing|crying|grimacing|verbal protests|"][textarea cols=40 rows=2]
Head: [checkbox name="head" value="Normocephalic, atraumatic|normal hair distributionnormal anterior fontanel||scalp tenderness|alopecia|swelling|"] [textarea cols=40 rows=2]
Face: [checkbox name="face" value="Symmetrical, without tenderness|no evidence of trauma|CN grossly intact||rash|swelling|ecchymosis|"] [textarea cols=40 rows=2]
Eye(s): [text] [checkbox name="eyes" value="Clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact, painless, without nystagmus, visual acuity grossly intact|PERL|cornea(s) clear|ant. chamber(s) clear||allergic shines|dennie lines|periorbital swelling|conjunctival injection|epiphora|conjunctival exudate|palpebral edema|palpebral exudates|chemosis|hyphema|subconjunctival hemorrhage|corneal abrasion|dysconjugate gaze|"] [textarea cols=40 rows=2]
Ear(s): [text] [checkbox name="ears" value="Symmetrical & intact auricles bilaterally, hearing to conversation intact|no tragal tenderness|clear canals without erythema or D/C|no FB visible in canals|TMs normal in appearance||tragal tenderness|swelling of external auditory canal|pustule in canal|cerumen in canal|purulent discharge in canal|dried up blood in canal|TM obscured by cerumen|TM red|pus behind TM|fluid behind TM|TM bulging|TM perforated|TM retracted|tube in TM|mastoid tenderness|"] [textarea cols=40 rows=2]
Nose: [text] [checkbox name="nose" value="Nares patent bilaterally, no facial swelling or discoloration|septum midline|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness|deviated septum|swollen & boggy mucosa|mucosal ulceration|mucosal congestion|clear discharge|yellow discharge|crusty discharge|active septal hemorrhage|dried up blood|"] [textarea cols=40 rows=2]
Mouth: [checkbox name="mouth" value="Tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions|normal bucal mucosa|normal dentition||poor dentition|single oral ulcer|multiple oral ulcers|gum swelling|tooth caries|"] [textarea cols=40 rows=2]
Throat: [checkbox name="throat" value="Normal voice, patent pharynx w/o swelling or exudates|swallows fluids without cough or chocking|uvula midline|clear pharynx w/o exudates||pharyngeal erythema w/o exudates|hoarseness|vesicles on soft palate|petechia on soft palate||pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules|"] [textarea cols=40 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=40 rows=2]
Lungs: [checkbox name="lungs" value="Normal work of breathing, symmetrical chest expansion, no stridor audible|clear and equal breath sounds bilaterally||SOB|stridor|intercostals retractions|wheezing|crackles|breath sounds decreased bilaterally|"] [textarea cols=40 rows=2]
Chest/CV: [checkbox name="cv" value="Chest wall atraumatic and non-tender|no SOB, no ankle edema|regular rhythm, no murmurs|pedal skin warm with good & equal pulses||tachycardia|irregular hear rhythm|systolic murmur|calf tenderness|ankle edema|varicosities|stasis discoloration||no axillary or supraclavicular LAD|chest wall tenderness|sternal tenderness|breast mass|breast tenderness|skin dimpling/retraction|"] [textarea cols=40 rows=2]
Abdomen: [checkbox name="abd" value="Normal visual inspection, no distension|not examined|normal active bowel sounds|soft non-tender|no bruit auscultated over AA and renal arteries||protruding|surgical scar|diffuse tenderness over entire abdomen w/o RRG|umbilical hernia|abdominal striae|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|"] [textarea cols=40 rows=2]
GU: [checkbox name="gu" value="Not examined|no CVAT bilaterally|no suprapubic tenderness||normal external genitalia|circumcised|uncircumcised|no inguinal LAD|smooth non-tender testes|+cremasteric reflexes bil|no skin lesions|no urethral discharge|testicular tenderness|urethral discharge|verrucous papules|vesicles|crusted lesions|pearly penile papules"] [textarea cols=40 rows=2]
MSK: [checkbox name="spine" value="No gross deformities, 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||C-spine tenderness|cervical DROM|neck pain with active motion|paracervical muscle spasm|trapezius tenderness w TPs||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 sitted SLR|positive sitted SLR|"] [textarea cols=40 rows=2]
Upper extremity(s) [text] [checkbox name="upper_extremity" value="Atraumatic w/o swelling, atrophy or deformity|free and painless ROM|strength, tone, & bulk symmetrica & grossly intactl|able to make tight grips|no vascular compromise|compartments soft w/o tension||+ Appley scratch|+ painful arc|deltoid tenderness|bicipital groove tenderness|tenderness|swelling|ecchymosis|"] [textarea cols=40 rows=2]
Lower extremity(s) [text] [checkbox name="lower_extremity" value="Atraumatic w/o swelling, atrophy or deformity|free and painless ROM|strength, tone, & bulk symmetrical & grossly intact|able to raise/lower foot against resistance|no vascular compromise|compartments soft w/o tension||+ McMurray|DROM|tenderness|swelling|ecchymosis|"] [textarea cols=40 rows=2]
Neuro: [checkbox name="neuro" value="Alert & oriented, gait, balance & coordination grossly intact|normal speech/vocalization|CN grossly intact|no gross motor deficits|sensation symmetrical & grossly intact|full weight bearing||Romberg without drift or sway|extremities strong w/o atrophy, tremor or fasciculations|reflexes normoactive|patellar DTR present and equal|flexor plantar reflex bilaterally||antalgic gait|wide gait|diffuse numbness w/o dermatomal pattern|tremor|"] [textarea cols=40 rows=2]
Behavior/attitude towards examiner: [checkbox name="behavior" value="Pleasant, cooperative|tactful||hostile|defensive|argumentative|seductive|flattering|evasive|suspicious|ingratiating|combative|rude|demanding|derogatory"] [textarea cols=40 rows=2]
Psych: [checkbox name="psych" value="Appropriate to age/situation|normal concentration and attention|memory intact to recent & remote events|good eye contact|speech fluid & coherent|organized thought process|appropriate judgment and insight||poor eye contact|agitated|anxious|irritable|indifferent|guarded||expansive affect|flat affect|labile affect||speech slurred|speech loud|speech slow|speech rapid|speech parsimonious|stuttering|tics||tangential thought|circumstantial thought|aberrant thought|flight of ideas|reports being target of persecution/discrimination|poor judgment & insight|"] [textarea cols=40 rows=2]
Skin: [checkbox name="skin" value="Grossly intact, no suspicious lesions, no rashes|no bruises|normal turgor||multiple tattoos|body piercings|poor turgor|dry|sweaty||"]
[textarea cols=40 rows=2] [checkbox name="single_lesion" value="erythema|induration|firm|soft|deep|mobile|fluctuant|painful|"]
[textarea cols=40 rows=2] [checkbox name="injury_wound" value="abrasion|excoriation|fissure|laceration|ulceration|ecchymosis|swelling|burn|scar|"]
[textarea cols=40 rows=2] [checkbox name="rash" value="generalized distribution|acral distribution|symmetrical|unilateral|linear|annular|arcuate|serpiginous|red scaly|red non-scaly|macular|popular|follicular|urticarial|targedoid|vesicular|pustular|purpuric|non-blanching|sharply-demarkated borders|indistinct borders|"] [textarea cols=40 rows=2]





Assessment/Plan


LABS

[textarea name="343435" default="sample text"]


Diagnosis:
[text name="633637" default="sample text"]

DDx:
[textarea name="837447" default="sample text"]
==============================================
PLAN: 
 
[textarea name="8333" default="sample text"]

Education:

Follow up:
[checkbox name="variable_1" value="option A|option B|option C"]