SOAP – Internal Medicine

[date name="variable_1" default=""]
IM Note, [select name="variable_1" value="Blue Team|Red Team|Yellow Team"], Dr. [text name="variable_1" default=""], [select name="variable_1" value="PGY1|PGY2|PGY3"], for Dr. [text name="variable_3" default=""].

S: [textarea name="variable_4" default="Patient was seen and examined."]

[text name="variable_1" default="No events were reported overnight."]

O: 
* Vital Signs: TEMP: [text name="variable_5" default=""] HR: [text name="variable_6" default=""] RR: [text name="variable_7" default=""] SPO2: [text name="variable_8" default=""] on [text name="variable_9" default=""] BP: [text name="variable_10" default=""]
* General Appearance: [select name="variable_11" value="NAD|Mildly distressed|Moderately distressed|Severely distressed|"], [select name="variable_12" value="well developed/well-nourished|underdeveloped/under-nourished|cachectic|"], [select name="variable_13" value="lying comfortably in bed|sitting comfortably on bed|sitting comfortably on chair|hunched over|"] [text name="variable_14" default=""]
* Head: [select name="variable_15" value="Normocephalic, atraumatic|"][select name="variable_15" value=", symmetrical face|, right facial droop|, left facial droop"] [text name="variable_16" default=""]
* Eyes: [select name="variable_17" value="PERRLA|Anisocoria|Fixed pupils|Unreactive to light only|Unreactive to accommodation only|"], [select name="variable_18" value="EOMI|dysconjugate gaze|strabismus|horizontal nystagmus|vertical nystagmus|torsional nystagmus|mixed nystagmus|4th n. palsy|6th n. palsy|"],  [select name="variable_19" value="conjunctiva clear|conjunctival congestion|conjunctival chemosis|conjunctival exudates|conjunctival icterus|conjunctival pallor|subconjunctival hemorrhage|"] [select name="variable_22" value=", bilateral|, left|, right|"] [select name="variable_20" value="normal eyelids|retracted eyelid|ptosis|palpebral swelling|"] [text name="variable_21" default=""]
* Ears: [select name="variable_22" value="Bilateral|Left|Right"] [select name="variable_23" value="external auditory canal clear|eythematous external canal|swollen external canal|erythematous and swollen external canal"][select name="variable_24" value="|, bilateral|, left|, right"] [select name="variable_25" value="|tympanic membrane clear|bulging tympanic membrane|retracted tympanic membrane"][select name="variable_26" value="|, bilateral|, left|, right"] [select name="variable_27" value="|absent tragal tenderness|tragal tenderness"][select name="variable_26" value="|, bilateral|, left|, right"][select name="variable_27" value="|absent mastoid tenderness|mastoid tenderness"][select name="variable_26" value="|, bilateral|, left|, right"] [select name="variable_27" value="|hearing grossly intact|sensorineual hearing loss|conductive hearing loss|mixed hearing loss"] [text name="variable_31" default=""]
* Nose: [select name="variable_28" value="No nasal discharge|Clear rhinorrhea|Purulent discharge|Epistaxis/Blood per nostril|"][select name="variable_29" value="|, normal nasal mucosa|pale, swollen mucosa|, bluish, swollen mucosa"]. [select name="variable_29" value="|No septal deviation|Septal deviation present"]. [select name="variable_29" value="|No septal perforation|Septal perforation present"]. [text name="variable_62" default=""]
* Oral: [select name="variable_28" value="Oropharynx clear|Erythematous oropharynx|Purulent oropharynx|"], [select name="variable_29" value="moist mucosa|dry mucosa|"],  [select name="variable_30" value="normal colored oral mucosa|pale oral mucosa|cyanotic oral mucosa|"] [text name="variable_31" default=""]
* Neck: [select name="variable_32" value="Supple|Stiff|Torticollis|"], [select name="variable_64" value="no cervical lymphadenopathy|left cervical lymphadenopathy|left cervical lymphadenopathy|bilateral cervical lymphadenopathy|"][select name="variable_75" value="|, left|, right|, bilateral|, diffuse|, total"] [select name="variable_95" value="|thromegaly|thyroid nodule|thyroid mass|hemithyroidectomy|thyroidectomy"] [select name="variable_85" value="with no tenderness|with tenderness|"][select name="variable_85" value="|, bilateral carotid bruits present|, right carotid bruit present|, left carotid bruit present"] [text name="variable_31" default=""]
* Heart: [select name="variable_98" value="Normal rate and rythm|Tachycardiac|Bradycardiac|Small, weak pulse|Large bounding pulse|Bisferiens pulse|Pulsus alternans|Bigeminal pulse|Pulsus paradoxicus|"], [select name="variable_79" value="normal S1, S2|wide splitting|fixed splitting|paradoxical splitting|3rd heart sound|4th heart sound|"], [select name="variable_54" value="no murmurs, rubs, or gallops|early systolic murmur|mid systolic (ejection) murmur|late systolic murmur|pan systolic murmur|early diastolic murmur|late diastolic mumrmur|presystolic murmur|continuous murmur|pericardial rub|gallop|"] [text name="variable_62" default=""]
* Chest: [select name="variable_54" value="Clear to auscultation bilaterally (normal vesicular breath sounds),|Bronchial breath sounds|Diminished breath sounds|Could not auscultate|"] [select name="variable_54" value="|on left|on right|on bilateral"] [select name="variable_54" value="|upper lung field,|lower lung field,|lung fields,"] [select name="variable_54" value="no wheezing|with wheezing|with stridor|"][select name="variable_54" value=", no crackles|, with crackles|"] [select name="variable_54" value="|on left|on right|on bilateral"] [select name="variable_54" value="|upper lung field|lower lung field|lung fields"] [text name="variable_62" default=""]
* Abdomen: [select name="variable_54" value="Normal bowel sounds|Hypoactive bowel sounds|Hyperactive bowel sounds|Absent bowel sounds|Could not auscultate|"], [select name="variable_54" value="not distended|distended|"], [select name="variable_54" value="not tender|with tenderness|"] on [select name="variable_54" value="on all quadrants|upper right quadrant|upper left quadrant|lower right quadrant|lower left quadrant|"], [select name="variable_54" value="no hepatosplenomegaly|with hepatsplenomegaly|with hepatomegaly|with spenomegaly|"], [select name="variable_54" value="|no bruits|with bruits|could not auscultate for bruits"], [select name="variable_54" value="no masses|with a mass|"] on [select name="variable_54" value="on all quadrants|upper right quadrant|upper left quadrant|lower right quadrant|lower left quadrant|"] [text name="variable_62" default=""]
* Musculoskeletal: [select name="variable_54" value="Normal muscle bulk|Decreased muscle bulk (atrophy)|"], [select name="variable_54" value="moves all limbs freely|limited range of motion|"], [select name="variable_54" value="no tenderness|with tenderness|"] [select name="variable_54" value="|on right|on left|on bilateral"] [select name="variable_54" value="|on all limbs|upper limb|lower limb|shoulder joint|elbow joint|wrist joint|hip joint|knee joint|ankle joint"] [select name="variable_54" value="no swelling|with swelling|"] [select name="variable_54" value="|right|left|bilateral"] [select name="variable_54" value="|on all limbs|upper limb|lower limb|shoulder joint|elbow joint|wrist joint|hip joint|knee joint|ankle joint"] [select name="variable_54" value="no masses|with a mass|"] [select name="variable_54" value="|on right|on left|on bilateral"] [select name="variable_54" value="|on all limbs|upper limb|lower limb"] [text name="variable_62" default=""]. Muscle Strength: [text name="variable_62" default=""].
* Extremities: [select name="variable_1" value="No significant deformity or joint abnormality|With significant deformity or joint abnormality|"]. [select name="variable_54" value="No edema|Edema +1|Edema +2|Edema +3|Edema+4|"] [text name="variable_62" default=""]. [select name="variable_54" value="Peripheral pulses +3|Peripheral pulses +2|Peripheral pulses +1|Peripheral pulses +4|"]  [text name="variable_62" default=""].
* Neurological: [select name="variable_54" value="No focal neurological lesions|Focal neurological lesion(s) present|"] [text name="variable_62" default=""]. [select name="variable_54" value="Cerebellar intact|Cerebellar defect(s) present|"] [text name="variable_62" default=""].
* Skin: [select name="variable_54" value="Normal color|Jaundiced|Cyanosed|Vitiligo|Other discoloration|Hypopigmentation|Hyperpigmentation|"]. [text name="variable_62" default=""]. [select name="variable_54" value="Normal texture|Abnormal skin texure|"] [text name="variable_62" default=""].

LABS, IMAGING, AND OTHER DIAGNOSTIC STUDIES: 
WBC [text name="variable_1" default=""] Hgb [text name="variable_1" default=""] Pl [text name="variable_1" default=""]
Hct [text name="variable_1" default=""]


Na [text name="variable_1" default=""] Cl [text name="variable_1" default=""] BUN [text name="variable_1" default=""] Gluc [text name="variable_1" default=""] K [text name="variable_1" default=""] HCO3 [text name="variable_1" default=""] Cr [text name="variable_1" default=""]

[textarea name="variable_53" default=""]

DIAGNOSES/ASSESSMENT& PLAN:

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ATTENDING PHYSICIAN'S NOTES/COMMENTS:
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