Table of Contents
To the Reader ix
Acknowledgments x
Abbreviations xi
Normal Lab Values xiv
How to Write a SOAP Note xix
I Medicine 1
1 Adult History & Physical, Preventive Maintenance 2
2 Allergic Rhinitis 5
3 Anemia, Iron-Deficiency 7
4 Appendicitis 9
5 Asthma 11
6 Bronchitis/Pneumonia 13
7 Chest Pain 15
8 Cholefithiasis/Cholecystitis 17
9 Conjunctivitis 19
10 Constipation 21
11 Delirium/Dementia 23
12 Diabetes Mellitus 25
13 Dizziness 27
14 Epididymitis/Prostatitis 29
15 Fibromyalgia 31
16 Gastritis/Gastroesophageal Reflux/Peptic Ulcer Disease 33
17 Gastrointestinal Bleed 35
18 Headache 37
19 Hyperlipidemia 39
20 Hypertension 41
21 Hyperthyroidism 43
22 Hypothyroidism 45
23 Nephrolithiasis 47
24 Obesity 49
25 Osteoarthritis 51
26 Pharyngitis/Tonsillitis 53
27 Sinusitis 55
28 Urinary Incontinence 57
29 Urinary Tract Infection 59
II Obstetrics & Gynecology 61
30 Well Woman Exam, Preventive Maintenance 62
31 First Trimester Visit 64
32 Second Trimester Visit 66
33 Third Trimester Visit 68
34 Amenorrhea 70
35 Bleeding During Pregnancy 72
36 Abnormal Uterine Bleeding 74
37 Dysmenorrhea/Pelvic Pain 76
38 Family Planning 78
39 Infertility 80
40 Mastalgia 82
41 Menopause 84
42 Pelvic Inflammatory Disease 86
43 Postpartum Visit 88
44 Premenstrual Syndrome/Dysphoric Disorder 90
45 Sexually Transmitted Infections 92
III Pediatrics 95
46 Newborn Exam 96
47 Well Child Exam (2-12 Months) 98
48 Well Child Exam (13-24 Months) 100
49 Well Child Exam (25 Months-Preadolescence) 102
50 Well Child Exam (Adolescence) 104
51 Abdominal Pain 106
52 Acute Gastroenteritis 108
53 Acute Otitis Media/Otitis Externa 110
54 Attention-Deficit/Hyperactivity Disorder 112
55 Fever 114
56 Heart Murmurs 116
57 Nocturnal Enuresis 118
58 Rash/Viral Exanthems 120
59 Respiratory Infection 122
60 Urinary Tract Infection 124
IV Dermatology 127
61 Acne 128
62 Atopic Dermatitis 130
63 Basal Cell Carcinoma 132
64 Bites (Animal/Human) 134
65 Burns 136
66 Cellulitis 138
67 Lyme Disease 140
68 Melanoma 142
69 Molluscum Contagiasum/Verruca 144
70 Psoriasis 146
71 Scabies 148
72 Squamous Cell Carcinoma/Actinic Keratosis 150
73 Tinea 152
74 Urticaria 154
V Orthopedic Conditions 157
75 Sports Medicine Screening Exam 158
76 Ankle/Foot Pain 160
77 Back Pain 162
78 Elbow Pain 164
79 Knee Pain 166
80 Neck Pain 168
81 Shoulder Pain 170
82 Wrist/Hand Pain 172
VI Psychiatry/Psychosocial Issues 175
83 Alcoholism 176
84 Anxiety/Panic Attacks 178
85 Bipolar Disorder 180
86 Child Abuse 182
87 Depression 184
88 Domestic Violence 186
89 Drug Abuse 188
90 Elder Abuse 190
Index 193
