SOAP Note – Gastrointestinal & Endocrine
Chief Complaint (CC) “neck swelling” PMH Patient denies PSH Surgical removal of benign left breast nodule 2 years ago Drug Hx No medication at the time Allergies NKA Subjective Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations PE B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI […]