I need to write a SOAP note and I don't want to 😴
S: Violet 7 is a 24 year old medical student with a PMH of Late Night SDN Syndrome (LNSDNS) who presents with insomnia and difficulty concentrating.
O: General: AAO x 3, NAD, pleasant
Vitals: T 100.2 noted, o/w WNL
HEENT: NCAT, EOMI, PERRLA, MMM, no lymphadenopathy, no thyromegaly, TM intact
CV: RRR, S1 S2 audible, no S3, S4, no g/r/m, PMI not displaced, no JVD, no carotid bruits, CR < 2 sec
Lungs: CTA bilaterally, no r/r/w, no egophany, tactile fremitus WNL
Abd: Soft, NT, ND, tympanic x 4, BS x 4, no organomegaly
Back: No step-offs, midline spine, no CVA tenderness
Ext: no cyanosis, no edema, + 2 peripheral pulses b/l
Neuro: CN 2-12 intact, 5/5 strength x 4 b/l w/ good tone, sensation to LT intact symmetrically and b/l,
RAM intact, finger-to-nose intact, proprioception intact, negative Romberg's, steady gait
A: Insomnia and Not-enough-give-a-**** Disorder (NEGASD)
P: Bedrest, F/u 1 day.