Soap Note Physical Exam

• [GET] Soap Note Physical Exam | new!
  
  
  She has also had knee pain and a recent finger sprain and a history of thrombophlebitis. Her heart rate is 80 and regular. Lung sounds are clear. Respirations are Lumbar spine is symmetrical. She is able to lie supine on the exam table, but she...
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• [FREE] Soap Note Physical Exam | HOT!
  
  
  She is having some difficulty getting comfortable and sleeping at night. We are going to try her on Robaxin mg in the evening. She can certainly take it during the daytime as well, if this does not cause any sleepiness or side effects, and for more...
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• Urology SOAP Note Sample Report
  As a Physical Therapist, you may work with patients who require an extra level of documentation for legal purposes. For example, those who suffered injuries in an accident caused by someone else, minors, people who are incarcerated, and so on. Data Collection for Future Reference Creating a record of detailed treatment notes allows a medical professional to build their own mini-research library. Information Sharing Among Peers Speaking of better accuracy, SOAP notes are widely accepted as the easiest type of medical record-keeping when it comes to sharing information among peers.
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• Cheat Sheet: Normal Physical Exam Template
  Your Physical Therapist SOAP notes play a big role in the overall care of a patient who almost always has other providers on their care team. When it comes down to it, writing SOAP notes gives your patients documentation their other caregivers can use to aid in the healing process. This is especially useful when you are working on a complicated case. If you want to write Physical Therapist SOAP notes that help you, your patient and their whole care team, include these elements outlined by the American Physical Therapy Association : Self-report of the patient Details of the specific intervention provided Equipment used.
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• How to Write Incredible Physical Therapist SOAP Notes
  He is asymptomatic and sleeps through the night. No dysuria, hematuria, frequency, urgency, or incontinence. He takes Flomax and metoprolol daily along with calcium and multivitamins. His recent PSA is 2. Prostate is about grams, rubbery, symmetrical in shape, slightly firmer along the right lateral border, but with no discrete nodularity. He has had a couple of sebaceous cysts, one of the back and one of the anterior chest wall, excised many years ago. He has noticed a small nodule in the posterior left scrotum, which he feels has doubled in size in the last six months. It has not been painful and has not drained. It has not previously been treated in any way.
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• How to Make SOAP Notes for Medical Workers
  He has no known allergies. PLAN: He will be scheduled for excision of the sebaceous cyst in the next few weeks. He returns today for followup and PSA check. PSA from two days ago was less than 0. We were pleased to see this result, and we do recommend that he receive PSAs in three-month increments. In terms of continence, he is doing well. He utilizes one partial pad per day. He has done his Kegel exercises regularly, and he feels that benefited well from his biofeedback preoperatively. We have encouraged him to continue with Kegels and do expect a full recovery. In terms of potency, he did have a bilateral nerve sparing procedure and is eligible for recovery of erections.
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• Understanding SOAP format for clinical rounds
  He is interested in this, and we have therefore outlined the therapeutic benefits of medications as well as vacuum pump therapy. He is aware that patients who utilize these therapies will have a better chance recovering than those who do not. For that reason, he will take Cialis 20 mg every three days and will use the vacuum pump multiple times a week. He does not have contraindications to do these therapeutic treatments. Status post laparoscopic radical prostatectomy with undetectable PSA. Stress incontinence.
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• Lumbar Strain SOAP Note Sample Report
  Likely erectile dysfunction. The patient has stress incontinence and leakage with coughing, laughing, and physical activity. Some frequency, urgency. No real prolapse noted. She was last seen a week ago, and there are no changes in the medical history. She denies any new medications, changes in medical diagnoses, or ER visits. Vagina was slightly atrophic. Minimal anterior and posterior compartment defects. Well-supported uterus in superior compartment.
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• ED Charting and Coding: Physical Exam (PE)
  Positive cough stress test. Rectovaginal: Firm. The patient underwent simple uroflow and had a normal voiding pattern. She underwent complex cystometrogram. She had her first sensation at 20 mL, normal desire to void at , a strong desire at with a maximum cystometric capacity at mL. She had a highly compliant bladder. She was asked to cough, Valsalva at each mL interval. She did leak urine with this at about mL.
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• Physical Exam Template
  There were no contractions or bladder contractions noted during the testing. She had a urethral closure pressure profile, which was measured at 70 cm of water. Valsalva and cough leakpoint at around 80 cm of water, on average. She then underwent a voiding pressure study. She voided total of mL. She had a flow of peak pressure 0. Mean bladder pressure at 9 cm of water, 52 mL residual. PLAN: Simple, minimally invasive sling. We went over the benefits and risks of the procedure. The patient understood and accepted these risks and wanted to proceed. The patient will call us regarding when she wants the procedure done.
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• Dizziness SOAP Note
  No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good dentition, no lesions. Tympanic membranes are clear. NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness. Nontender to palpation. No wheezes, rhonchi, or rales.
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• History and Physical Exam: Introduction
  No murmurs, gallops, or rubs. No skin or nipple retractions. No nipple discharges or masses. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus are normal. Normal sphincter tone. No masses. Prostate is smooth and nontender and without nodules or fluctuance. No masses or tenderness. Gait is normal. Deep tendon reflexes are intact. Recent and remote memory is intact.
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• How to Document a Patient Assessment (SOAP)
  Appropriate mood and affect. SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Eyes: Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nose: Nasal mucosa is pink and moist. Septum is midline. Mouth: Oral mucosa is pink and moist. Dentition is good. There is no jugular venous distention noted. There are no carotid bruits noted. There are no palpable masses. There are no crackles, wheezes or rhonchi noted. There is no crepitus on palpation. No murmurs are noted. There are no lifts, heaves or thrills noted on palpation. There are good bowel sounds. There is no rebound or guarding. There is no evidence of hernia. SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor. There is no clubbing, cyanosis or edema. Sensation to light touch and pain is intact bilaterally.
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• Physical Exam - The SOAPnote Project
  There is no apparent mood disorder. Vital Signs: T: [x] degrees. P: [x] beats per minute. R: [x] breaths per minute. BP: [x] mmHg. Face: No lesions. Eyes: Conjunctiva pink. Sclera are anicteric. EOMs are full. Ears: The right and left ear canals are clear. Both tympanic membranes are intact. Nose: No external or internal nasal deformities. Nasal septum is midline. Mouth: The lips are within normal limits. The dentition is good. Tongue is midline with no lesions. The oral cavity is clear. Pharynx: Tonsils are normal size and clear. No exudates. Neck: Supple. No lymphadenopathy. Thyroid: No thyromegaly or masses. Chest: Clear to auscultation and percussion. Heart: Regular sinus rhythm. No gallops or murmurs. Abdomen: Soft, nontender. Normoactive bowel sounds. No organomegaly or masses. Extremities: No cyanosis, edema or deformities. Neurologic: Grossly intact. Skin: No lesions.
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• DOD PHYSICAL EXAM - The SOAPnote Project
  Dizziness: Case 1 — Mr. J reports that when he is dizzy, it feels as though the room is spinning. His first episode occurred 3 days ago when he rolled over in bed. The spinning sensation was very intense, causing nausea and vomiting. It lasted less than 1 minute. On further questioning, Mr. J reports that he had a similar episode 5 years ago. Other than nausea, he has no other symptoms. Specifically, he has not had definitive CNS symptoms like new severe headache or neck pain, diplopia, numbness, weakness, dysarthria, or trouble walking.
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• Neurology SOAP Note Sample Reports
  He has no risk factors that increase the likelihood of central vertigo such as diabetes mellitus, hypertension, coronary artery disease or peripheral vascular disease which increase the likelihood of cerebrovascular disease , no history of active cancer, and he is not taking any anticoagulants which increase the likelihood of CNS hemorrhage. He has no prior history of neurologic complaints eg, unilateral vision loss of optic neuritis or motor weakness. On physical exam, he appears anxious.
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• General Adult Physical Exam - The SOAPnote Project
  HEENT exam reveals extraocular muscles intact with 15 beats of horizontal nystagmus on left lateral gaze. This stops after repeating the maneuver several times. Optic disks are sharp and visual fields are intact to confrontation. Cardiac, pulmonary, and abdominal exams are normal. On neurologic exam, cranial nerves are intact except for nystagmus. Hearing is grossly normal. Gait and finger-to-nose testing are normal. Romberg is negative. At this point, the Dix-Hallpike maneuver should be performed to evaluate positional nystagmus. J reports intense vertigo with the maneuver.
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• SOAP note - Wikipedia
  Horizontal nystagmus with a rotary component is noted, which lasts for 20 seconds. After repeating the maneuver, the nystagmus disappears. There are no alarm features to suggest central vertigo. The duration of each vertiginous episode suggests BPPV rather than vestibular neuritis or Meniere disease. There is no tinnitus or hearing loss to suggest Meniere disease. Further testing is not indicated. An Epley maneuver is performed resulting in resolution of Mr. One month later he returns and is feeling well.
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• Office Notes-Normal Female Exam Template - 1 (Medical Transcription Sample Report)
  SOAP presentations and notes vs. One involves the Match and sometimes has its own nerve-racking associations. The SOAP format can help. Subjective Notes For the subjective segment, lead with a one-sentence reminder of who your patient is. Give an overview of how your patient did overnight and anything major that may have happened since you last rounded. Objective Notes Open this segment by discussing vital signs, including blood pressure, pulse, respirations, temperature, and oxygen saturations. Give the total intake, followed by a breakdown. Then present your exam, and after that, give laboratory results.
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• SOAP Notes - StatPearls - NCBI Bookshelf
  Sometimes, there will be pertinent imaging that can be presented here as well. When it comes to the plan, it can be challenging to know how much detail to go into. One of the best things you can do is ask a resident to take a look at your plan, and then ask their advice on how much to present. It can save you time and frustration in the long run. Final Tips Learn what your attendings prefer. When in doubt, ask your attendings on your first day how much detail they like in their presentations. Different attendings want you to present differently—with some wanting you to go over your whole note in detail and others just wanting you to get to the point as quickly as possible.
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