OTC KNEE PAIN
Employee presents to the window with a specific request for Aleve Allergies: NKDA Current Medications: lisinopril - according to EE Aleve is okay to take in B/P meds Medical condition (Reason for request): Calf pain/Swelling Medication was self-selected by employees. Medication directions, warnings, and directions were available to employees at the time of the request General: Well appearing, well-nourished, in no distress. Oriented x 3, normal mood and affect. Stabile Gait denies pain when walking. Inspection Calf: Presence swelling +2 distal medial R calf, proximal to R ankle. Inspection Feet: Document bounding artery pulses and <3 capillary refill. + Sensation. Range of motion (full bilateral). Flexion to (full bilateral). Abduction to (full bilateral). Internal Rotation (full bilateral). External rotation (full bilateral). Strength (full bilateral). Palpation: (Tenderness) to palpation mid-calf, radiates to ankle). Recommended EE follow-up with PCP for further evaluation.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 139 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote