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Basic SOAP.docx - Patient: CC: HPI: Current Medications:...

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Patient:CC:HPI:Current Medications:Allergies:PMHx: DepressionPSHx: UnremarkableSocial Hx:No drug use.No alcohol use.No tobacco use.Family History:Mother: Breast Cancer, deceased.Father: NoneROS:General: No weight loss, fever, chills, or fatigue.HEENT: No vision loss, blurred vision, double vision, or yellow sclera. No hearing loss, sneezing,congestion, runny nose, or sore throat.SKIN: No itching or rash.CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.RESPIRATORY: No productive cough, no SOBGASTROINTESTINAL: No nausea, vomiting or diarrhea, no abdominal pain.NEUROLOGICAL: No headaches, dizziness, syncope, paralysis, ataxia, numbness, or tingling.MUSCULOSKELETAL: No joint pain or stiffnessHEMATOLOGIC: No anemia, bleeding, or bruising.LYMPHATICS: No enlarged nodesPSYCHIATRIC: No history or mental health disordersENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

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Term
Spring
Professor
Domegu
Tags
Headache

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