Urgent Care SOAP note [Fall22Clinical]

URGENT CARE VISIT
Patient Name:
Age/Sex:
DOB:CHIEF COMPLAINT:
HPI:PMH:
ROS:
General: Denies wt. changes, fever/chills, fatigue.
HEENT: Denies any changes in vision, nasal discharge/epistaxis,
sore throat/hoarseness or hearing problems.
CV: Denies chest pain, dyspnea, palpitations, edema.
Pulmonary: Denies cough, hemoptysis, wheezes, SOB.
GI: Denies anorexia, N/V/D, abd. pain, constipation, heartburn.
GU: Denies urinary symptoms at this time. Denies erectile dysfuntion.
Musk: Denies Decreased ROM, arthralgias, swelling, pain
Neuro: Denies weakness, numbness, HAs, seizure, dizzines/vertigo.
Skin: Denies rashes, erythema, skin breakdown, itching.SH:Allergies:MEDICATIONS:
Active Outpatient Medications (including Supplies):
Active Outpatient Medications Status
=========================================================================******************************************************************
MEDICATION RECONCILIATION:
Reviewed medications with patient, including over-the-counter
and herbals.
Medications reconciliation was performed with the following
results:
The patient was provided with a list of his/her medications?
Yes
If a medication list was not provided, please give the reason:*******************************************************************
PHYSICAL EXAM:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Weight:
Temperature:
Pain:GENERAL: Pleasant yo white male. NAD.
HEENT: TMs with sharp light reflex bilaterally. PERRLA. EOMS intact. Sclera
white, conjunctiva non-swollen. Nares are patent, no exudates. Nasal mucosa
is non-swollen and red. Throat is non-swollen, no pnd. Uvula moves midline.
NECK: Supple, no bruits or masses.
CARDIOVASCULAR: RRR, S1 S2. Radial, brachial, femoral, DP and TP pulses are
2+/4.
RESPIRATORY: Clear sounds posteriorly to the bases bilaterally.
ABDOMEN: Active sounds in all quads. No bruits, masses, or organomegaly.
GU: External genitalia normal looking. Sphincter tone is normal. Prostate
is smooth, small, no nodules.
MUSCULOSKELETAL: MAE. FROM. Strength is = side to side in the UE and LE.
SKIN: Warm and dry.
NEURO: OX3. CN II-XII intact. DTRs 2+/4 all around.
PSYCHIATRIC: Alert, interactive. Good eye contact. Appropriate responses.
HEME/LYMPH/IMMUNE: No nodal enlargement in the cervical chains, axillae, or
groin.
ASSESSMENT AND PLAN:
HEALTH CARE MAINTENANCE:
Flex/sig:
Tetnus:
Pneumonia vax:
flu shot:
DRE/PSA:Clinical Reminders:DISPOSITION/FOLLOW-UP:
URGENT CARE VISIT
Patient Name:
Age/Sex:
DOB:CHIEF COMPLAINT:
HPI:PMH:
ROS:
General: Denies wt. changes, fever/chills, fatigue.
HEENT: Denies any changes in vision, nasal discharge/epistaxis,
sore throat/hoarseness or hearing problems.
CV: Denies chest pain, dyspnea, palpitations, edema.
Pulmonary: Denies cough, hemoptysis, wheezes, SOB.
GI: Denies anorexia, N/V/D, abd. pain, constipation, heartburn.
GU: Denies urinary symptoms at this time. Denies erectile dysfuntion.
Musk: Denies Decreased ROM, arthralgias, swelling, pain
Neuro: Denies weakness, numbness, HAs, seizure, dizzines/vertigo.
Skin: Denies rashes, erythema, skin breakdown, itching.SH:Allergies:MEDICATIONS:
Active Outpatient Medications (including Supplies):
Active Outpatient Medications Status
=========================================================================******************************************************************
MEDICATION RECONCILIATION:
Reviewed medications with patient, including over-the-counter
and herbals.
Medications reconciliation was performed with the following
results:
The patient was provided with a list of his/her medications?
Yes
If a medication list was not provided, please give the reason:*******************************************************************
PHYSICAL EXAM:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Weight:
Temperature:
Pain:GENERAL: Pleasant yo white male. NAD.
HEENT: TMs with sharp light reflex bilaterally. PERRLA. EOMS intact. Sclera
white, conjunctiva non-swollen. Nares are patent, no exudates. Nasal mucosa
is non-swollen and red. Throat is non-swollen, no pnd. Uvula moves midline.
NECK: Supple, no bruits or masses.
CARDIOVASCULAR: RRR, S1 S2. Radial, brachial, femoral, DP and TP pulses are
2+/4.
RESPIRATORY: Clear sounds posteriorly to the bases bilaterally.
ABDOMEN: Active sounds in all quads. No bruits, masses, or organomegaly.
GU: External genitalia normal looking. Sphincter tone is normal. Prostate
is smooth, small, no nodules.
MUSCULOSKELETAL: MAE. FROM. Strength is = side to side in the UE and LE.
SKIN: Warm and dry.
NEURO: OX3. CN II-XII intact. DTRs 2+/4 all around.
PSYCHIATRIC: Alert, interactive. Good eye contact. Appropriate responses.
HEME/LYMPH/IMMUNE: No nodal enlargement in the cervical chains, axillae, or
groin.
ASSESSMENT AND PLAN:
HEALTH CARE MAINTENANCE:
Flex/sig:
Tetnus:
Pneumonia vax:
flu shot:
DRE/PSA:Clinical Reminders:DISPOSITION/FOLLOW-UP:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 310 boilerplate words
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: