Case Sim

Name: [text name="variable_1" default=""]
Age: [text name="variable_2" default=""]
Informant: [text name="variable_50" default=""]
Sex: [text name="variable_51" default=""]
Ethnicity:  [text name="variable_52" default=""]

**Subjective**
Chief complaint: [textarea cols=79 rows=2 default=""]

History of present illness: 
[textarea name="variable_4" default="Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Times,"]

Past medical history: 
[textarea name="variable_17" default=""]
Past surgical history:
[textarea name="variable_18" default=""]
Allergies: [text name="variable_60" default=""]
Medications:
[textarea name="variable_20" default=""]
Family history:
[textarea name="variable_26" default=""]
OB/GYN history:
[textarea name="variable_80" default=""]

Social history:
Occupation - [text name="variable_21" default=""]
Living situation - [text name="variable_22" default=""]
Caffeine - [text name="variable_82" default=""]
Tobacco - [text name="variable_23" default=""]
Alcohol - [text name="variable_24" default=""]
Illicit drugs - [text name="variable_25" default=""]

Review of systems:
[textarea name="variable_5" default="-General: Denies fever or chills, fatigue, malaise, or weight changes."]
[textarea name="variable_6" default="-HEENT: Patient denies headaches, vision changes, rhinorrhea, sore throat or mouth pain."]
[textarea name="variable_7" default="-Cardiac: Denies chest pain, palpitations, or edema."]
[textarea name="variable_8" default="-Pulmonary: Denies shortness of breath, cough, or change in sputum production."]
[textarea name="variable_9" default="-GI: Denies nausea or vomiting, abdominal pain, diarrhea or constipation, melena, or change in appetite."]
[textarea name="variable_10" default="-GU: Denies dysuria, hematuria or incontinence."]
[textarea name="variable_11" default="-Musculoskeletal:  Denies myalgias, arthralgias, weakness, numbness or tingling."] 
[textarea name="variable_12" default="-Dermatologic: Denies rashes or erythema."]
[textarea name="variable_13" default="-Neurologic: Denies seizures or changes in sensation."]
[textarea name="variable_14" default="-Psychiatric: Denies depression, anxiety or mental health concerns. Patient is not suicidal.[textarea name="variable_15" default="-Endocrine: Patient denies polyphagia, polydipsia, polyuria or heat/cold intolerance."] 
[textarea name="variable_16" default="-Hematologic/lymphatic:Denies abnormal bleeding/bruising."]

==============================================
**Objective**
Vital signs: 
T - [text name="variable_30" default=""] F
BP – [text name="variable_31" default=""] mm Hg
HR - [text name="variable_32" default=""] bpm
RR - [text name="variable_33" default=""] rpm
HT - [text name="variable_80" default=""] in
WT - [text name="variable_81" default=""] lbs
Physical Examination
[textarea cols=80 rows=4 default="-GENERAL APPEARANCE: Well developed, well-nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=4 default="-HEENT: Normocephalic, EOM intact, PERRLA, anicteric, no injection, fundus WNL, no papilledema, tympanic membranes intact, non-inflamed, no congestion, no nasal discharge. Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Neck supple, non-tender without lymphadenopathy, masses or thyromegaly"]
[textarea cols=80 rows=4 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=4 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=4 default="GENITOURINARY: no dysuria/frequency/blood in urine/incontinence"]
[textarea cols=80 rows=4 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=4 default="-MUSCULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea cols=80 rows=4 default="-SKIN: Skin normal color, texture and turgor with no lesions or eruptions, no rashes, bruising, nail or hair changes."]
[textarea cols=80 rows=4 default="-NEUROLOGICAL: CN II-XII intact. No weakness, headache, or other pain strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[textarea cols=80 rows=4 default="-PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."]

==============================================
**Assessment**
Labs/Diagnostics:
[textarea name="variable_45" default=""]

Differential Diagnosis:
[textarea name="variable_46" default=""]
==============================================
**Plan**
[textarea cols=80 rows=2 default="#1 Problem"]
[textarea cols=81 rows=2 default="#2 Problem"]
[textarea cols=82 rows=2 default="Education"]
[textarea cols=83 rows=3 default="RTC"]
Name:
Age:
Informant:
Sex:
Ethnicity:

**Subjective**
Chief complaint:


History of present illness:


Past medical history:

Past surgical history:

Allergies:
Medications:

Family history:

OB/GYN history:


Social history:
Occupation -
Living situation -
Caffeine -
Tobacco -
Alcohol -
Illicit drugs -

Review of systems:












==============================================
**Objective**
Vital signs:
T - F
BP – mm Hg
HR - bpm
RR - rpm
HT - in
WT - lbs
Physical Examination











==============================================
**Assessment**
Labs/Diagnostics:


Differential Diagnosis:

==============================================
**Plan**



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 52 form elements, 73 boilerplate words, 18 text boxes, 34 text areas, 52 total clicks
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: