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
=========================================================================





******************************************************************
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, 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:
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
=========================================================================





******************************************************************
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, 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:

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