Soap Template
CC:
S:
PMH/PSH:
Medications:
O:
Vitals: OralT - BP -HR -RR - spo2 %RA
General Appearance: Animated, well groomed, responds quickly to questions
Skin, hair, nails: Skin color flushed, warm and moist. Hair with average texture. Nails without clubbing or cyanosis. No suspicious nevi. No rash, petechiae, or ecchymoses.
HEENT: Sclera white, conjunctiva pink. Tympanic membranes with good cone of light, no redness or bulging. Nasal mucosa pink, septum midline; no sinus tenderness. Pharynx without exudates or tonsillar swelling. Neck supple. No lymphadenopathy.
Respiratory: Symmetric with good expansion. Breath sounds vesicular, equal/clear bilat.
Cardiac: Apical impulse in 5th ics at left midclavicular line, no thrill. Crisp S1 and S2, not diminished or accentuated. No extra heart sounds or murmurs.
Peripheral Vascular System: Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Radial and dorsalis pedis pulses are 2+ and symmetric.
Abdomen: Protuberant with active bowel sounds, soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle tenderness.
Musculoskeletal system: Full range of motion in all joints. No evidence of swelling or deformity.
Neurological system: Alert and cooperative. Thought process coherent. Oriented to person, place, and time. Cranial Nerves II through XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements, finger-to-nose, heel-to-shin intact. Gait with normal base. Maintains balance with eyes closed. No pronator drift. Pinprick, light touch, position, and vibration intact. Reflexes 2+ and symmetric.
Important Diagnostics:
A:
S:
PMH/PSH:
Medications:
O:
Vitals: OralT - BP -HR -RR - spo2 %RA
General Appearance: Animated, well groomed, responds quickly to questions
Skin, hair, nails: Skin color flushed, warm and moist. Hair with average texture. Nails without clubbing or cyanosis. No suspicious nevi. No rash, petechiae, or ecchymoses.
HEENT: Sclera white, conjunctiva pink. Tympanic membranes with good cone of light, no redness or bulging. Nasal mucosa pink, septum midline; no sinus tenderness. Pharynx without exudates or tonsillar swelling. Neck supple. No lymphadenopathy.
Respiratory: Symmetric with good expansion. Breath sounds vesicular, equal/clear bilat.
Cardiac: Apical impulse in 5th ics at left midclavicular line, no thrill. Crisp S1 and S2, not diminished or accentuated. No extra heart sounds or murmurs.
Peripheral Vascular System: Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Radial and dorsalis pedis pulses are 2+ and symmetric.
Abdomen: Protuberant with active bowel sounds, soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle tenderness.
Musculoskeletal system: Full range of motion in all joints. No evidence of swelling or deformity.
Neurological system: Alert and cooperative. Thought process coherent. Oriented to person, place, and time. Cranial Nerves II through XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements, finger-to-nose, heel-to-shin intact. Gait with normal base. Maintains balance with eyes closed. No pronator drift. Pinprick, light touch, position, and vibration intact. Reflexes 2+ and symmetric.
Important Diagnostics:
A: