‘PEgenitalM

GEN: Well appearing, relaxing comfortably, no acute distress
HEENT: Normocephalic, atraumatic, EOMI, hearing grossly normal
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs, no peripheral edema
PULM: Symmetric chest rise, no increased work of breathing, lungs clear to auscultation bilaterally, no cough/crackles/wheeze/rhonchi
GI: Flat, normoactive bowel sounds, nondistended, nontender, no masses or hepatosplenomegaly
GU: Chaperone present in room for examination. Penis is circumcised without evidence of lesions or penile discharge. Scrotum is unremarkable with bilaterally descended testicles and no tenderness on palpation. Testicles are smooth and circumferential without evidence of mass.
MSK: Normal gross movement of bilateral upper and lower extremities
SKIN: Pink, warm, dry; no rashes
NEURO: Alert and oriented, no focal neurologic deficit
PSYCH: Cooperative, answers questions appropriately, pleasant affect
GEN: Well appearing, relaxing comfortably, no acute distress
HEENT: Normocephalic, atraumatic, EOMI, hearing grossly normal
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs, no peripheral edema
PULM: Symmetric chest rise, no increased work of breathing, lungs clear to auscultation bilaterally, no cough/crackles/wheeze/rhonchi
GI: Flat, normoactive bowel sounds, nondistended, nontender, no masses or hepatosplenomegaly
GU: Chaperone present in room for examination. Penis is circumcised without evidence of lesions or penile discharge. Scrotum is unremarkable with bilaterally descended testicles and no tenderness on palpation. Testicles are smooth and circumferential without evidence of mass.
MSK: Normal gross movement of bilateral upper and lower extremities
SKIN: Pink, warm, dry; no rashes
NEURO: Alert and oriented, no focal neurologic deficit
PSYCH: Cooperative, answers questions appropriately, pleasant affect

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 129 boilerplate words
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: