URGENT CARE VISIT – COMPLETE SOAP NOTE

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.
-G.I: Denies anorexia, N/V/D, abd. pain, constipation, heartburn.
-GU: Denies urinary symptoms at this time. Denies erectile dysfuntion.
-MS: Denies Decreased ROM, arthralgias, swelling, pain 
-Neuro: Denies weakness, numbness, HAs, seizures, dizzines/vertigo. 
-Skin: Denies rashes, erythema, skin breakdown, itching.

SH:



Allergies:

MEDICATIONS:
Active Outpatient Medications (including Supplies):
 
     Active Outpatient Medications                          Status
=========================================================================





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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:


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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, S1S2.  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: