Full General Exam

SUBJECTIVE:[text default="CC:" size=100]
[textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"]

Pt was referred by:[text memo="referred by"]
[text size=5] year old [comment memo="Race: "] [text size=10 ][select value="male|female"] 
[checkbox name="variable_1" value="Patient with previous history of: "][text size=50]
[checkbox name="variable_2" value="They were last seen in my office on :"][text size=10][checkbox name="variable_2" value="Surgical intervention on :"][text size=10]
[checkbox name="variable_3" value="Pt complains of "][text size=50][checkbox name="variable_4" value="Location: "][text size=50]
[checkbox name="variable_5" value="Started: "] [text size=50]
[checkbox name="variable_6" value="Associated symptoms: "]
Medication List:
[textarea name="variable_7" default=""]
Pertinent Past Medical History:
[textarea name="variable_38" default=""]
[checkbox name="variable_12" value="Family History: "][checkbox name="variable_13" value="Melenoma  M__  F__  P-GF__ P-GM__ M-GF__ M-GM__ |Cancer M__  F__  P-GF__ P-GM__ M-GF__ M-GM__ | Stroke M__  F__  P-GF__ P-GM__ M-GF__ M-GM__ | Diabetes M__  F__  P-GF__ P-GM__ M-GF__ M-GM__ | HTN M__  F__  P-GF__ P-GM__ M-GF__ M-GM__ | Heart Disease M__  F__  P-GF__ P-GM__ M-GF__ M-GM__"][text size=50]
[link memo="Go to Social History" mark="Social History"]
[mark name="Social History"]
[checkbox name="variable_18" value="|Married |Divorced |Widow/Widower |Single | Children:|Smoke   ____PPD ____Years | Alcohol  ____DPD | Drugs"][text size=50]

Physical Examination

[textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea cols=80 rows=1 default="RESPIRATORY: no cough/sputum/SOB/chest pain. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea cols=80 rows=1 default="GENITOURINARY: no dysuria/frequency/blood in urine/incontinence"]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: no constipation/diarrhea/blood in stool/melena.Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions, no rashes, bruising, nail or hair changes."]

[textarea cols=80 rows=1 default="medical Dx"] 

[textarea cols=80 rows=2 default="#1 Problem"]
[textarea cols=80 rows=2 default="#2 Problem"]
[textarea cols=80 rows=2 default="#3 Problem"]
[textarea cols=80 rows=2 default="#4+ Problem"]

[textarea cols=80 rows=5 default="summary of visit"]

Pt was referred by:referred by
year old Race:

Medication List:

Pertinent Past Medical History:

Go to Social History
Social History

Physical Examination




Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.28, 42 form elements, 19 boilerplate words, 12 text boxes, 16 text areas, 10 checkboxes, 1 drop downs, 1 links, 1 comments, 52 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

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

More SOAPnotes by this Author: