SOAP outline (Adults)
CC: XX Subjective * HPI: Patient X.X. is a XX-year-old male/female who is here for XX. She/He is an established patient with the clinic/New patient at the clinic. Patient is present here today with XX. Patient appears relaxed, makes good eye contact and speaks clearly and easily. [Insert various concerns and diagnoses] Example: * Hypertension: Patient presents for chronic health management of hypertension. Denies/Admits palpitations, chest pain, tachycardia. Patient has/has not been been taking BP measurements at home, AVG BP 120s/130s/ 80s. Medications include: XX. Side effects include: None/drowsiness/constipation/other. * ROS -Skin: denies rashes or lesions; denies new nevi -HEENT: 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: denies pain, lumps, or lymphadenopathy -Cardiovascular: denies chest pain, palpitations, or tachycardia. -Respiratory: denies cough, congestion, wheezing, or dyspnea -Gastrointestinal: denies abdominal discomfort, heartburn, reflux; reports regular voids and stools w/no issues -Genitourinary: denies any problems -Musculoskeletal: denies joint stiffness, joint pain or swelling -Integumentary/Breast: denies rash, pain, or masses -Neurological: denies seizures, sensory loss, headaches, migraines, or lethargy -Hematologic/Lymphatic: denies bruising, bleeding, and lymphadenopathy generally -Endocrine: no reported hair loss; skin is warm and dry; no night sweats reported -Psychiatric: denies anxiety and depression. Objective * Vitals: HR XX, RR XX Wt XXlb, Ht XX in, BMI XX index, BP XX, Spo2 XX% * Physical Exam -Skin: warm and dry skin, even tone throughout, appropriate for ethnic background; no lesions or new nevi present -HEENT - thin hair, evenly distributed on scalp; Eyes: no redness or swelling in conjunctiva, lid margins touch; pupils reactive to light and accommodation; Ears: clear with no redness, swelling, or discharge; tympanic membranes intact, dull with good movement; hearing grossly intact; Nose/Sinuses: nasal mucosa without inflammation, nose symmetrical with no redness, swelling, or drainage; Throat: no masses, redness, or tenderness noted; no erythema in pharynx -MOUTH - lips moist; Teeth: white, straight, with no redness to gums. Tongue pink with no areas of redness or lesions. Mucosa pink, smooth and moist -NECK/LYMPH NODES - neck supple, trachea midline; no goiter; no swelling or lymphadenopathy noted; neck muscles symmetric; lobes not felt -THORAX/LUNGS - respirations regular and unlabored; lungs clear to auscultation in all lobes anterior and posterior; negative for shortness of breath or tachypnea -CARDIOVASCULAR - rate regular without murmurs, gallops, or rubs. PMI nondisplaced; no appearance of JVD -BREASTS/CHEST - deferred - no reported issues -ABDOMEN - round, soft, BX x4 active non-tender to palpation; no bruits detected over aorta, renal, or iliac arteries; negative hepatosplenomegaly (-); non-distended, rounded with no obvious masses or lesions present, patient reports no areas of tenderness; even skin tone and smooth surface; umbilicus midline, no signs of herniation -GENITALIA - deferred - no reported issues -RECTAL - deferred - no reported issues -EXTREMITIES - no clubbing, no edema -PERIPHERAL VASCULAR - no edema at ankles; no varicosities in lower extremities, capillary refill <3 sec -MUSCULOSKELETAL - ROM to all extremities/patient’s expected normal; no joint deformities or swelling -NEUROLOGIC - Mental Status: alert and cooperative. Thought processes are coherent with good insight. Oriented to person, place, and time. Motor: fair muscle bulk with fair tone. Strength: no weaknesses reported. Cerebellar: point-to-point movements intact. Sensory: no loss of sensation noted. Reflexes: intact *Labs: XX *Diagnostics: XX ASSESSMENT/PLAN I10 - HYPERTENSION * [Insert plan and education here] * Start/Continue/Refill/Increase/Decrease [medication name, dose] Follow-up: 3 months [chronic health management & labs]
There are 0 form elements.