REASON FOR VISIT: Pharyngitis.

SUBJECTIVE:  The patient is a (XX)-year-old male with a past medical history of acute pharyngitis who presents with a 1-week history of feeling itchy throat and having chest congestion.

The symptoms are milder from yesterday; although, mother notes that the patient had a low-grade temperature on Tuesday and was feeling nauseous yesterday, all of which has resolved at present.  No nasal congestion.

The patient does have cough occasionally, no discharge.  The patient denies any dysphasia, no symptoms with his ears.

OBJECTIVE:

VITAL SIGNS:  Weight 81 pounds, blood pressure 114/82, heart rate 80, temperature 98.8 degrees Fahrenheit and oxygen saturation 100% on room air.

HEENT:  Ears:  Tympanic membrane visualized with light, clear. No erythema, no effusion, nares patent, no discharge.  Larynx:  No tonsillar edema, no tonsillar exudate, no erythema noted.

NECK:  No lymphadenopathy appreciated.

HEART:  Regular rate and rhythm.

LUNGS:  Clear to auscultation bilaterally on the anterior and posterior pulmonary fields.

ASSESSMENT AND PLAN:  This is a (XX)-year-old male with past medical history of acute pharyngitis and otitis media who presents with most likely an acute viral pharyngitis with some components of a viral URI.

At this point, the mother as well as the patient was asked to take symptomatic management by taking Tylenol or ibuprofen for pain management as well as for fever, increase oral hydration, rest and monitor symptoms closely.

They will return if needed if symptoms worsen. The patient noted his understanding to these instructions.

After a period of treatment with conservative management using compression therapy, the ulcer ultimately healed. A vein valve duplex study of the right leg demonstrated incompetence of right greater saphenous vein beginning at the saphenofemoral junction extending down through the thigh. Deep vein valve closure times were normal.

Right greater saphenous vein stripping and ligation was recommended to prevent recurrent ulceration.

OBJECTIVE: The patient is a (XX)-year-old man who appears his stated age. He is awake and alert. The blood pressure is 130/94. Pulse is 86 and regular. Lungs: Clear. Heart sounds are regular. Examination of the legs reveals venous varicosities in the greater saphenous distribution of the right leg with significant trophic changes of chronic venous hypertension in the lower leg.

ASSESSMENT AND PLAN: In summary, the patient has right greater saphenous venous valvular incompetence. We have recommended a right greater saphenous vein stripping and ligation to lower his risk of recurrent venous ulceration.

We have gone over the risks of the procedure in detail with him. He has signed a consent form today. His operation is scheduled sometime in the near future as an outpatient. We have asked him to avoid taking aspirin or anti-inflammatory medications within one week of the operation.

Samples of Soap Notes Transcription Examples #2

SUBJECTIVE: The patient is a (XX)-year-old female. She is a nonsmoker. She has smoked in the past but stopped in (XXXX). She does not drink alcohol regularly. Past history is positive for UTIs, a remote vasovagal reaction. She has had costochondritis, right hip fasciitis, and mild osteoarthritis of the hips and knees. She takes over-the-counter multivitamin daily, calcium with vitamin D daily, vitamin C daily, omega-3 daily.

OBJECTIVE: Her vital signs include a blood pressure of 112/82, pulse 62. She is 5 feet 8 inches, weight 146. BMI is 22.6. HEENT: Pupils are reactive to light. Fundi and disks appear flat. Thyroid: Negative. Pharynx is clear. Neck: Supple. Lungs: Clear to auscultation and percussion. CVA: Without tenderness. Heart: Regular rhythm. No gallop, rub or murmur. Carotids had no bruits. Breasts: Minimal cystic changes without mass, axillary adenopathy or nipple discharge. Abdomen: Soft, flat, nontender. No organomegaly. She has healed scars from removal of benign moles from the right abdominal wall. Extremities: No edema, stenosis or clubbing. Pedal pulses are intact. Neurologic exam is nonfocal. Rectal: Stool guaiac negative. No rectal masses are noted.

ASSESSMENT AND PLAN: The patient’s exam is well within normal limits. We would like her to return for fasting chem-7, liver and lipid profiles, CBC, urinalysis and EKG. She will have a screening colonoscopy performed. She had a bone density within the last year, which was still within normal limits. She will return in six months. Call sooner if any problems.

Samples of Soap Notes Transcription Examples #3

SUBJECTIVE: The patient presents today after a tick bite, which he noticed yesterday. He must have picked up the tick this weekend, although he cannot be certain.

OBJECTIVE: On examination of his right posterior hip and buttock, there is a small dime-sized area of erythema with no surrounding erythema or discomfort or pruritus.

ASSESSMENT AND PLAN: Tick bite. The patient feels well. He has no complaints of myalgias or fatigue, headaches or malaise. We will treat him with a two-dose treatment of doxycycline 100 mg, and he will call if he does not feel well in the coming days and weeks. We will recheck a Lyme antibody as well as ehrlichiosis and babesiosis antibody in four weeks to make certain that he is all set, since it is not clear how long the tick was in place.

Samples of Soap Notes Transcription Examples #4

SUBJECTIVE: The patient is a (XX)-year-old female who comes in today with a chief complaint of cough. She was seen twice over the winter for cough and nasal congestion. She was given azithromycin in January with minimal relief. She states that five days ago she developed a tickle in the back of her throat. This persisted and evolved into low-grade fever at 99 degrees, cough with occasional green sputum.

She has shortness of breath only after a coughing fit. She has had difficulty sleeping at night secondary to her cough. She denies sinus tenderness. She has rhinorrhea but no nasal congestion. No hearing or vision changes. She has been taking Mucinex, Delsym, and Tylenol Cold with some relief. She reports muscle aches and fatigue but no fever.

OBJECTIVE: Temperature 99.6, blood pressure 132/82, pulse 80, respiratory rate 18, oxygen saturation 97% on room air. General: The patient is nontoxic appearing; although, her voice is raspy. HEENT: Watery eyes. Pupils are equal, round and reactive to light. Extraocular movements are intact. No sinus tenderness. Oropharynx is clear. Boggy nasal turbinates bilaterally, right greater than left. Tympanic membranes are clear. Neck: Supple, some nontender submandibular lymphadenopathy palpable. Cardiovascular: Irregularly irregular 2/6 systolic ejection murmur. Lungs: Wheezing at the right base with decreased fremitus.

Chest x-ray shows borderline congestive heart failure, which is stable. Status post AVR. Pacemaker in place.

Pre-albuterol peak flow was documented at 125-150. Post-albuterol peak flow 100-150. Lung examination post-albuterol nebulizer was significant for diffuse wheezing bilaterally. The patient symptomatically improved with some production of green sputum.

ASSESSMENT AND PLAN: A (XX)-year-old female presenting with allergic rhinitis and asthma.
1. Allergies: The patient has been instructed to take Claritin daily.
2. Asthma: The patient has been given a prescription for Advair 250/50 mcg b.i.d. as well as an albuterol rescue inhaler. She has been instructed on how to utilize these inhalers. She will be seen by Pulmonary and then follow up with her primary care physician.

Samples of Soap Notes Transcription Examples #5

SUBJECTIVE: The patient is a (XX)-year-old female, gravida 2, para 1, status post stage IIIA adenocarcinoma of the uterus with metastatic disease to the anterior peritoneum and left ovary.

The patient had a robotic-assisted laparoscopic total hysterectomy, bilateral salpingo-oophorectomy and staging for grade 2-3 of 3 endometrioid adenocarcinoma of the uterus with squamous differentiation.

She completed Taxol and carboplatin chemotherapy and pelvic radiation. She has no GYN complaints. Bowel and bladder are without problem.

OBJECTIVE: Alert female in no acute distress. Vital Signs: Stable. Blood pressure 122/82, weight 178 pounds, height 5 feet 8 inches. Neck: Supple without thyromegaly. Breasts: Symmetrical, status post lumpectomy, left with palpable lymph node, which has been there for two years according to the patient. No cervical, axillary or supraclavicular adenopathy. Abdomen: Soft, nontender, well-healed scars, no palpable masses. Gynecologic: Normal external genitalia. Normal vagina. Surgically absent cervix. ThinPrep Pap smear performed. Bimanual: Uterus surgically absent. No nodularity. Adnexa negative without adenopathy or nodularity or fixation. Rectovaginal is negative.

ASSESSMENT: Normal gynecologic exam, status post IIIA adenocarcinoma.

PLAN:
1. Follow up in three months with Dr. John Doe.
2. Follow up in six months here.
3. The patient knows to call should she have any problems.

Samples of Soap Notes Transcription Examples #6

SUBJECTIVE:  The patient is a (XX)-year-old woman who comes in today for wart treatment on the feet. I had seen her about a month ago, had frozen some warts off her left heel and also the left fourth toe. She notes she thinks some of them are gone.

OBJECTIVE:  Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the hands and feet.

ASSESSMENT AND PLAN:  Plantar wart. On her fourth toe, she had three hyperkeratotic papules and also on the base of the third toe she had one and on her left heel she had several punched areas in the area of cryotherapy and only three of them had residual warts, and these were frozen again with liquid nitrogen and also she had a single one on her palm. We will see her back in a month.

Samples of Soap Notes Transcription Examples #7

SUBJECTIVE:  A (XX)-year-old man comes in for rash on the penis going on a month. No discharge. No fever. No pain. No unusual contacts. No new creams, lotions or chemical detergents. No contact dermatitis issues. It has been going on about a month, little bit irritation.

OBJECTIVE: On examination, he has an erythematous plaque on the scrotum, which is about 3 x 4 cm, slightly raised, confluent with irregular borders, not tender to touch. No weeping or oozing or discharge. He has a similar lesion underneath the foreskin on the dorsal aspect of the shaft, kind of ring like pattern at the base of the glans. No adenopathy. No mites. No excoriations. No lymphadenopathy.

ASSESSMENT AND PLAN:  Penile rash, question etiology. This looks to me like a psoriatic plaque. He does not have any pitting in his fingernails. No lesions on his elbows or his knees. He said he has had rosacea in the past and treated with some MetroGel. I also wondered if it could be lichen planus on the penile shaft. We do not have any other good idea. Of course, this could be a local irritation of contact dermatitis, but again this has been present a month with an itch. We are going to give him a little Lotrisone cream. We told him we do not think it is anything worrisome. We told him he should follow up with a dermatologist in 2 to 4 weeks if it is not resolved.

Samples of Soap Notes Transcription Examples #8

SUBJECTIVE:  The patient is doing well and has no complaints except that she is having trouble taking her weight. Her last bone density showed some improvement. She does walk about a mile and a half a day. She is feeling well. She again refuses colonoscopy and mammogram. We did spend some time trying to convince her of doing both and also starting to do self-breast exam.

OBJECTIVE: Blood pressure 142/80, pulse 60 and regular, weight 154, which is stable. Chest:  Clear to P and A. No rales, rhonchi or wheezes. Heart:  Normal sinus rhythm without murmurs or megaly. Extremities:  No edema.

ASSESSMENT:  Osteopenia.

PLAN:  Continue with Fosamax. Return in 6 months.

MEDICATIONS:
1. K-Dur.
2. Glucophage.
3. Avandia.
4. Florinef.
5. Topamax.
6. Relafen.
7. Darvocet p.r.n.
8. Ditropan XL.
9. Klonopin 0.5 mg b.i.d.
10. Macrobid 100 mg daily.
11. Zocor 40 mg.
12. Dilantin 600 mg daily.
13. Phenergan 25 mg q.h.s. p.r.n.

REVIEW OF SYSTEMS: See form.

OBJECTIVE:
VITAL SIGNS: T: 97.6. P: 74. R: 18. BP: 112/72.
HEENT: NC/AT. PERRLA. No icterus or conjunctival inflammation. TMs clear B/L. Nasal mucosa pink, no exudate. Oropharyngeal mucosa normal. No lesions or exudates.
NECK: Supple. No JVD, adenopathy or bruits.
LUNGS: Clear to auscultation bilaterally.
HEART: S1/S2, RRR.
ABDOMEN: Soft, nontender. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema. Diffuse deformities due to achondroplastic dwarfism.

ASSESSMENT AND PLAN:
1. We will call in her Dilantin at 500 mg and 100 mg totaling 600 mg a day. These are extended release tablets.
2. The patient will have her Topamax increased back up to 4 tablets a day from 3. She states that in the recent past Dr. John Doe has evaluated her VP shunt and that there was no evidence of malfunction. However, we will get a CT of her brain to make sure that there are no problems there as the last one was done around a year back.
3. Lab work from earlier this month was reviewed. HbA1C is 5.2 denoting excellent control of diabetes. However, phenytoin level was 5.9, which prompted the recent change in her Dilantin level. We feel her headaches are probably due to recurrent low-grade seizures and not due to any problem with the VP shunt as she has been fairly asymptomatic after the change in the dose. Hopefully, increasing the Topamax to 4 a day will also help. Her LFTs are normal. We will see her again in 6 weeks and see how she is doing and review the CT of the brain.

DIAGNOSES:
1. Seizure disorder.
2. Diabetes mellitus type 2.
3. Normal pressure hydrocephalus.
4. Achondroplastic dwarfism.

DATE OF ADMISSION: MM/DD/YYYY

CHIEF COMPLAINT: Rapid heart rate.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department by squad. Apparently, just prior to arrival, he left work, was in his car, when his heart started racing. He states that he did have some chest tightness, 4/10 in intensity. No shortness of breath, nausea or vomiting. The patient states he had an ablation done in the past. He states he forgot to take his digoxin the last few days. He has never had a stress test.

PAST MEDICAL HISTORY:
1. SVT.
2. Hypertension.

MEDICATIONS:
1. Digoxin.
2. Toprol.

ALLERGIES: None.

SOCIAL HISTORY: The patient denies tobacco use. Occasionally, he drinks alcohol.

FAMILY HISTORY: The patient’s father has had a history of hypertension, and the patient’s grandmother has had a history of coronary artery disease.

REVIEW OF SYSTEMS: All systems are reviewed and otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: BP 152/108, temperature 98.4, pulse 190, respirations 18, O2 sat 98% on room air.
GENERAL: The patient is a well-developed male who appears anxious.
HEENT: Moist mucous membranes.
NECK: Supple, no JVD.
HEART: Tachycardic, otherwise regular rhythm, S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, obese.
EXTREMITIES: No clubbing, cyanosis or edema.

LAB RESULTS: Chest x-ray shows no acute findings by my reading. EKG shows a supraventricular tachycardia with a rate of 190. No acute findings on reading. Troponin normal.

WBC 14.8, otherwise normal CBC. Digoxin level 0.5. Chem-7 is normal, except for a glucose of 118.

EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. An IV was established in his left antecubital region. He was found to be in supraventricular tachycardia. He was given 6 mg of adenosine without conversion. He was given a repeat dose of 12 mg without conversion. He was bolused with Cardizem 20 mg and started on a drip at 15 mg an hour. He was rebolused with 25 mg of Cardizem. His rate began to come down into the 150s range and then he converted into a sinus rhythm. His old charts were reviewed. We did discuss the patient with Dr. John Doe, who is covering for his cardiology group, and the patient was discharged in good condition.

MEDICAL DECISION MAKING: The patient is a (XX)-year-old male with a supraventricular tachycardia. We will discharge him to home. He is to take his medications as directed. He is to follow up with his cardiologist and return if symptoms worsen.

DISPOSITION: Home.

DIAGNOSIS: Acute supraventricular tachycardia, resolved.

ER SOAP Note Sample #2

CHIEF COMPLAINT: Bilateral eye itching.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents to the emergency department complaining of a 3-day history of eye itching and swelling. The patient states this started in her right eye 3 days ago and spread to her left eye yesterday. Today, both eyes have been bothering her. The patient states it is a little sore around her eyes, but her main complaint is that they are itchy. She has had some clear tearing but no purulent discharge. She states her right eye is a little bit more blurry than usual. She has no eye pain. No sneezing. No runny nose. She had similar symptoms to these a year ago. They were somewhat milder, and she did not seek medical attention. She denies any cough. She denies any pain with eye movement. She denies any foreign body sensation and denies any injury.

PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.

ALLERGIES: None.

CURRENT MEDICATIONS: Per medical reconciliation form.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Positive for one pack per day tobacco use, occasional alcohol use. Negative for illicit drug use.

REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbances, neck pain, chest pain, shortness of breath or abdominal pain. All other systems are negative, except as noted in the HPI.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 118/76, pulse 74, respiratory rate 18, temperature 98.4, pulse ox 98% on room air.
GENERAL: The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, react to light. Extraocular movements are intact. Sclerae nonicteric. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. The patient has no pain with palpation over the globe itself. In her periorbital soft tissues, she has redness and swelling present, but it is not cellulitic redness; it is more of an irritated allergic reaction redness. She has no tenderness to palpation around her eyes. She has no purulent drainage. The oropharynx is clear. Pink and moist mucous membranes.
NECK: Supple, no lymphadenopathy, no thyromegaly. Trachea is midline.
LUNGS: Clear to auscultation bilaterally.
NEUROLOGIC: She is intact. Moving all four extremities symmetrically and spontaneously and following commands. Her left eye was tested. Visual acuity was tested and is 20/50. Her right eye visual acuity was 20/50 as well.
SKIN: Warm and dry. No evidence of rash other than is noted around the eyes.

LABORATORY RESULTS/RADIOLOGY: None.

EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. She remained hemodynamically stable throughout her stay. She received 50 mg of Benadryl and was discharged home.

MEDICAL DECISION MAKING: The patient presents with evidence of urticaria and allergic-related eye swelling. She has no evidence at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis. She has no evidence of ocular pain to suggest that she would have acute angle glaucoma. This would be unusual in both eyes anyway. She has no evidence of ruptured globe. No evidence of acute trauma and no evidence of cellulitis at this time. She is hemodynamically stable for discharge.

IMPRESSION: Urticaria.

PLAN:
1. The patient is to take Benadryl and Claritin as needed.
2. The patient is to follow up with her clinic, both for this and for medication refills that she is going to need in the near future.
3. She is to return for significant worsening of her symptoms, development of eye pain, worsening of her redness or swelling despite therapy or other concerns.
4. The patient verbalized understanding of the discharge instructions.

DISPOSITION: Discharged home in good condition.

ER SOAP Note Sample #3

SUBJECTIVE: The patient is without complaints, except he would like his baclofen pump addressed so that he can focus his attention on improving his functional abilities.

OBJECTIVE: The patient is afebrile with vital signs stable. The patient is 5 feet 8 inches tall and weighs 156 pounds. The head and neck are unremarkable. Pupils are equal, round, and reactive to light. Extraocular movements are intact. The patient is wearing eyeglasses. There is no apparent facial asymmetry. Heart and lung examinations are within normal limits. The abdomen is soft and nontender with active bowel sounds. A baclofen pump was noted in the left lower quadrant of the abdomen. Knee-high Ace wraps/compression stockings were in place.

ASSESSMENT AND PLAN:
1. Rehabilitation: A team conference was held today to review the patient’s functional goals and progress. The patient requires standby assistance with stand pivot transfers. The patient is independent with catheterization using a Coude catheter. Standby assistance/supervision is required for feeding, grooming, for bathing at the transfer tub bench, for upper extremity dressing, for bowel management, and for bed to wheelchair transfers. Minimal assistance is required for lower extremity dressing, bladder management, toilet transfers, and tub transfers. Based on the patient’s functional goals and progress, his tentative discharge date was established. The patient was told of this and was in agreement with the plan. However, he would like to focus on his baclofen pump for a portion of the rehabilitation stay. Continue comprehensive inpatient rehabilitation.
2. Spasticity: Under fair control. The neurologist will be contacted as far as further evaluation of the baclofen pump is concerned. A dye study is yet to be done.
3. Pain: Under fairly good control. Continue present management.
4. Bladder management: As previously mentioned, the patient is independent with intermittent catheterization. Continue present management.
5. Bowel management: Improving. Continue to work on a regulated program.
6. Hypertension: Under fair control. Continue present management.
7. Lower extremity edema: Improving. The lymphedema management team is assisting with his care.
8. Dementia: Workup in progress. The patient continues to be seen by the neurologist.

SUBJECTIVE: Starting Thursday last week, the patient had an acute sore throat as well as a mild fever. The fever was at its greatest on Saturday and the temperature was 102 degrees. Approximately Thursday last week, the patient came in for evaluation and was given penicillin for presumed strep throat. The patient did not feel any better on Saturday and so he presented to the emergency department for further evaluation.

In the emergency department, he was changed from penicillin to azithromycin. He was also given nystatin for thrush. He took those medications through today’s visit. Last night and this morning, the patient was feeling that his sore throat and his temperature are much improved. He has continued to take his medication as ordered. His appetite has been a little bit diminished, but he has been drinking adequate fluid to void about 5-7 times per day.

He is also concerned about 3 lesions in his mouth that have come up in the last 3 days. Of note, he is a type 1 diabetic and reports his sugars have been in control but he is concerned about an approximately 8 pound weight loss since March of this year. He is unsure what might be causing this.

OBJECTIVE:
VITAL SIGNS: Reviewed and reconciled.
GENERAL: The patient is a (XX)-year-old male in no acute distress.
HEENT: Normocephalic and atraumatic. Hearing and vision are grossly intact. Pupils are equal, round, reactive to light and accommodation. Sclerae white. Conjunctivae pink. Posterior pharynx is erythematous. Tonsils: Three white plaques with erythematous base measuring 2-5 mm across, located on right soft palate, sublingually, and lower lip. Thin line of erythema along the gumline, top and bottom. Tongue is mildly white. No cervical lymphadenopathy. Moves neck in all directions without difficulty.
LUNGS: Even unlabored respirations clear to auscultation bilaterally.
HEART: Regular rate and rhythm.

ASSESSMENT AND PLAN: This is a (XX)-year-old male who comes in with complaints of sore throat, fever and lesions in the mouth. His sore throat and fever are resolving, and the discomfort in his mouth is improving. The lesions are herpes simplex and will resolve without any intervention.

He should continue to take his azithromycin and his nystatin to completion. For any discomfort, he can take ibuprofen or acetaminophen in over-the-counter dosing. He should expect that his symptoms continue to resolve over the next 5-7 days.

We would like the patient to come back for evaluation in approximately 1 month. This is to better understand if the weight loss is related to this acute illness or if it is related to a long-term issue. The patient is to call back with any further questions or concerns. The patient verbalized understanding of this plan and agrees.

SUBJECTIVE: The patient states that his weekend went well. In particular, he states that his therapeutic pass/community reentry pass, though trying, was quite an eye-opening experience. He states that the experience was good for him.

OBJECTIVE: Temperature 99.0 degrees, pulse 88, respirations 20, and blood pressure 122/58. The head and neck examination was unremarkable. A Miami J collar was worn. The patient states he is not prepared to wear a soft cervical collar because it is not fitting well. He is waiting for a Philadelphia collar. Heart and lung examinations were within normal limits, except for a paradoxical pattern of respiration. The abdomen was soft, nontender, with active bowel sounds. There was no guarding or rebound tenderness. Thigh-high Ace wraps and TED hose were in place. The patient is wearing Stryker boots to pad his heels.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. A therapeutic pass yesterday was quite instructive for him. A team conference will be held tomorrow to review his functional goals and progress. Continue comprehensive inpatient rehabilitation.
2. Spine stability: Stable with soft cervical collar, though the patient continues to use a Miami J collar. Awaiting the Philadelphia collar.
3. Pain: Very little, if any, complaints except for occasional shoulder discomfort. Continue myofascial technique to the tight muscle groups in the upper trapezius muscles. Continue pain medications as written.
4. Bowel/bladder management: We will discuss this further during team conference. Working towards a regulated program. The patient and his family are involved with this.
5. Elevated temperature: Continues to fluctuate though a general trend of improvement is noted. The patient continues to receive ciprofloxacin for a urinary tract infection.
6. Left common femoral deep venous thrombosis: The INR today was 1.8. We will continue the Coumadin 7.5 mg daily and recheck the INR tomorrow. We hope to see a pattern and adjust the Coumadin accordingly.
7. Stage III sacral decubitus ulcer: Continues to heal with the electrical stimulation and nutritional supplements. We will evaluate this further during skin rounds tomorrow. We will likely continue the current plan of care.

Physical Medicine and Rehab SOAP Note Sample Report #2

SUBJECTIVE: The patient is without complaints today. However, he would nod off at times during the bedside evaluation. His father was at the bedside as well.

OBJECTIVE: Temperature 98.2, pulse 86, respirations 18, and blood pressure 92/52. Intermittent catheterization volume recorded, so far today, was 180 mL. The patient had a bowel movement earlier today. Head and neck examination showed the patient closing his eyes and nearly falling asleep one occasion. However, pupils are equal, round, and reactive to light. A Miami J collar was in place. Heart and lung examinations were within normal limits, except for a paradoxical pattern of respiration. The abdomen was soft and nontender with active bowel sounds. An abdominal binder was worn. The sacral dressing was intact. There was no lower extremity edema.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient is participating fully with encouragement in therapies. Discussions about spinal cord injury have been started. Continue comprehensive inpatient rehabilitation evaluation and treatment. Continue the prednisone taper.
2. Spine stability: Stable with Miami J collar. Continue present management.
3. Orthopedic: Surgical wounds are healing well. Continue spine precautions. The patient is scheduled for orthopedic followup next week.
4. Pain: Under good control. Perhaps, the patient may be able to be weaned from some of the medications as he is easily falling asleep. However, this could also be tiredness because of his decreased endurance.
5. Stage III sacral decubitus ulcer: Stable. The patient’s father again asked whether he could have a KinAir bed. He was told that the AccuMax overlay is appropriate for the patient and that his skin is healing. Continue wound care as written.
6. Pulmonary: Stable. Continue to work on improving the pulmonary status and diaphragm strength.
7. Neuropathic pain in the lower extremities: Reported more so in the left foot. The patient would like to hold off on adding Elavil to his treatment plan at this time. He will continue to use the Neurontin. The patient is aware that the Elavil will not interfere with the healing process.

Physical Medicine and Rehab SOAP Note Sample Report #3

SUBJECTIVE: The patient is without complaints. She states she was able to use the BiPAP overnight.

OBJECTIVE: Temperature 97.0 degrees, pulse 69, respirations 20, and blood pressure 113/48. The head and neck examination was unremarkable. The patient has a BiPAP machine at the bedside. A PICC line was noted in the right arm. A left exotropia was noted with dysconjugate gaze. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. There was a urostomy site as well as a colostomy site on the abdomen. There was also a PEG tube site. Knee-high TED hose was worn.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. She is showing fairly good endurance to be able to perform these activities. Continue comprehensive inpatient rehabilitation.
2. Hypertension: Good control. Continue present management. We may need to decrease some of the medications.
3. Lymphoma: Stable and followed by Dr. John Doe.
4. Depression: Slightly upbeat. Continue supportive therapy and medications as needed.
5. Bowel/bladder management: Manage with urostomy and colostomy. We will work towards a regulated program as well as teaching the family how to perform ostomy care.

She had an MRI in the past that showed some sort of synovial cyst that was diagnosed back in December. She states that her pain in her hip has been related to activities. She has pain going up and down stairs but it is just on the outside.

She denies any groin pain. She has a job that requires her to be up on her feet. The pain is worse at night. The patient saw her primary care physician. She was recommended to have an injection for her spine for synovial cyst, but she decided to not pursue this due to the lack of pain in her low back. She points to the outside of her hip, which she says is tender as well.

OBJECTIVE: The patient has point tenderness over the greater trochanter in the right hip. She has pain laterally with flexion of her hip and adduction of the hip. Range of motion of the right hip is about 10 to 20 internal rotation and 30 or 40 degrees external rotation but is symmetric bilaterally. She has 5/5 iliopsoas, quadriceps, hamstrings, gastrocnemius soleus, EHL and AT bilaterally. Sensation is intact to light touch grossly. She has negative Trendelenburg sign. The patient can stand on 1 leg for 5 seconds bilaterally without any weakness. Abduction strength is 5/5, but she does complain of pain on the right hip, on the outside of her hip. She has negative bicycle sign and Trendelenburg sign bilaterally.

IMAGING: Radiographs from December showed good joint space bilaterally, maybe some posterior inferior signs of some early osteoarthritis on the lateral, otherwise unremarkable.

ASSESSMENT: The patient has some trochanteric bursitis of the right hip.

PLAN: Today, we gave an injection with 80 Kenalog with 4 mL of 1% lidocaine. She was explained the risks and benefits. She has had this in the past and understood. We will have her follow up in 3 months. If she is still complaining of symptoms, we have instructed her to do some exercises to strengthen her abductors as well as stretching for iliotibial band.

He states that he feels quite healthy and that is why has never sought any medical care. However, a month ago, he started developing a dry cough, which 1 week later turned into a productive cough of purulent sputum.

He was seen in a walk-in clinic last week, where they did a chest x-ray; however, at that time, they said there was no need for antibiotics. Despite over-the-counter remedies, the patient’s symptoms have persisted and have not improved at all. This is in the setting of having recurrent measured temperatures, most recently at 101.4.

He denies any shortness of breath or wheezing with this. He does have associated rhinitis and has had some sick contacts also. His kids have been ill with similar symptoms over the last couple of weeks. He denies any recent travel and did not get his flu shot this year.

He denies any pleuritic chest pain and has not had any diarrhea, muscle aches, neck pain or photophobia. He has had intermittent headaches but none for a couple of days.

PAST MEDICAL HISTORY: Not significant; however, the patient did have a positive PPD on arrival to the US but a negative chest x-ray. He denies any exposure to tuberculosis in the past.

SOCIAL HISTORY: The patient is a nonsmoker. Occasionally drinks. He is married and has children. He exercises infrequently; however, he states that his diet is quite balanced.

ALLERGIES: NKDA.

FAMILY HISTORY: The patient’s father had diabetes.

OBJECTIVE: General: The patient is a well-appearing male in no distress. Vitals: Heart rate is 72, blood pressure is 122/82, and temperature is 98.4. Examination of his hands reveals that he has got no clubbing, no pallor. His pulse is regular with a good volume and no abnormal character. Examination of the head and neck reveals he has no jugular venous distention, no adenopathy. His pharynx is mildly erythematous but has no exudate or tonsillar enlargement. Pupils are equal, round and reactive to light. He has no thyromegaly. Chest is clear to auscultation bilaterally. Heart: Sounds S1 and S2 are present. No added sounds, no murmurs. Abdomen: Soft, nontender, nondistended, with bowel sounds auscultated diffusely. He has no organomegaly. Peripherally, he has got no edema. Good pedal pulses.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old gentleman coming in with cough and also for general health maintenance with no significant past medical history.
Cough: Given the fact that his symptoms have persisted and he has been recurrently febrile despite over-the-counter remedies, we feel it is likely that he has a bacterial bronchitis. For now, we will give him a 5-day course of azithromycin. Chest x-ray was done, which the patient states was normal. We will obtain a report of that in the interim.
Health maintenance: As mentioned, the patient has no past medical history of note. At this time, we will check total cholesterol and direct LDL. We will also get a baseline CBC and metabolic profile given the history of diabetes in the family.

SUBJECTIVE: Nicholas is a (XX)-year-old, right-hand dominant, previously community ambulatory Hispanic male with a past medical history significant for osteochondroma of right distal femur and nicotine dependence who presents for a second opinion regarding right leg pain. In June XXXX, he sustained an open right distal tibia/fibular fracture and underwent debridement, irrigation and intramedullary nailing performed at an outside facility. He had no problems with wound healing problem or infection in the postoperative period. He went to have his proximal and distal locking screws removed in November. His fracture has gone on to heal; however, he continues to have lower leg pain centered at the fracture site. He had seen Dr. John Doe recently, and he presents upon referral for another opinion. Again, he denies any history of infection after his surgery. He denies any other orthopedic symptoms. He does have a patch of decreased sensation over the lateral aspect of the forefoot and at the fracture site. He is a laborer, and he is on his feet all day. He is starting a new job next week. He denies any fevers, chills or night sweats or any other constitutional symptoms.

PAST MEDICAL HISTORY:  As above.

PAST SURGICAL HISTORY:  As above in addition to excision of osteochondroma, right femur, hydrocele repair, and right wrist surgery.

ALLERGIES: None.

MEDICATIONS: None.

SOCIAL HISTORY: The patient smokes approximately half a pack of cigarettes on a daily basis. He denies alcohol or illicit drugs.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: Significant for right leg pain.

OBJECTIVE: On examination of the right lower extremity, the surgical and traumatic wounds are completely healed. There are no local signs of infection. There is no soft tissue swelling, ecchymosis or edema. The foot is warm and well perfused with brisk capillary refill. Dorsalis pedis pulse is palpable and strong. Sensation is grossly intact to light touch distally in the distribution of the sural, saphenous, superficial, peroneal, deep peroneal and tibial nerves. There is decreased sensation, however, over the dorsolateral aspect of the foot. There is no tenderness to palpation over the knee or ankle. There is no tenderness to palpation at the tibia. There is no tenderness to palpation at fracture site. Active range of motion of the knee is from full extension to 155 degrees of knee flexion. Arc motion is pain-free. The knee is stable to varus-valgus stress testing at 0 and 30 degrees of flexion. There is no tenderness to palpation about the malleoli. Range of motion of the ankle is from 10 degrees of dorsiflexion to 45 degrees of plantarflexion. Arc motion is pain-free. There is no calf pain, swelling or tenderness to palpation. His gait is examined. It is nonantalgic in nature. He has no pain with weightbearing at the present time.

Radiographs of the right tibia demonstrate a well-aligned, healed distal third tibia fracture with associated fibular fracture. Proximal and distal interlocking screws have been removed.

ASSESSMENT AND PLAN: History of debridement and irrigation of open right distal tibia fracture treated with trimming, irrigation and intramedullary nailing. The diagnosis was reviewed in detail with his mother. Given history of open fracture, there is certainly concern about chronic occult infection; however, recent C-reactive protein is completely normal and, clinically, he does not have any signs of infection. His fracture has gone onto clinical and radiographic union and is well aligned. He does have some muscle weakness, specifically, quadriceps, hamstrings and gastrocnemius muscle complex. We do feel outpatient physical therapy is indicated to work on range of motion exercises as well as conditioning and strength training. This may improve some of his symptoms. I do not feel that hardware removal is indicated at the present time. He does have some issues with chronic pain, and we do feel that evaluation by a pain management specialist is indicated. We have made a referral to Dr. Jane Doe. We have given him a prescription for physical therapy, and we will see him back in approximately 8-10 weeks for repeat clinical and x-ray examination with AP and lateral x-rays of the right tibia. He understands the treatment plan above.

He was seen on Monday by Dr. John Doe at the Vascular Center regarding the wounds of his lower extremity to evaluate him for the report of greater than or equal to 50% stenosis of his right posterior tibial artery as well as to assess him for potential for closure procedure for this marked edema that he experiences. Dr. John Doe said that they were in agreement that the probable cause of his lower extremity ulcers is venous insufficiency, which they believe to be stage VI. Their recommendation was to continue with the compression stockings. Their plan will be to follow him up in two months at which time they will repeat a venous reflux study to see if there is a possibility of intervention that may be helpful to him.

OBJECTIVE: VITAL SIGNS: Temperature is 36.6, pulse is 86, respiratory rate is 20, and blood pressure is 134/52. GENERAL: The patient is an obese Hispanic male who is in no acute distress. He is alert. He is cooperative. He is pleasant in nature. EXTREMITIES: Examination of his ulcers reveals ulcer #1 to be located in the right medial distal portion of his lower leg. It measures 1.3 x 1.3 x 0.2. There is no sinus tract, no tunneling or undermining associated with that wound. There is only a very small amount of serous drainage coming from the wound. He has a small amount of granulation tissue in the wound base with a large amount of yellow fibrinous slough in that wound. The wound has experienced a small amount of epithelialization since we saw him last week. There is no evidence of infection as there is no odor, no erythema, no abnormal discharge coming from the wound.

Ulcer #2 is of the right medial lower extremity just above ulcer #1. It measures 1.0 x 1.0 x 0.2. There is no sinus tract, no tunneling, no undermining associated with it. There is only a small amount of serous exudate coming from the wound. There is no ability to appreciate any granulation tissue in the wound base. It is completely covered with a yellow fibrinous slough. There is no epithelialization occurring with that wound. There is no evidence of any infection as there is no erythema, no odor, no abnormal discharge coming from the wound.

Ulcer #3 is of left lateral leg. It measures 1.1 x 0.9 x 0.3. There is no sinus tract, no tunneling and no undermining associated with it. There is a small amount of serous drainage coming from it. There is no ability to appreciate any granulation tissue in the wound base as there is a large amount of yellow fibrinous slough overlying the whole wound base obscuring any good granulation tissue. There may be minimal epithelialization to this wound. There is no evidence of infection as there is no erythema, no odor, no abnormal discharge coming from the wound.

PROCEDURES PERFORMED: The operative procedure today is an excisional debridement on ulcer #1. Ulcer #1 is located in the right medial distal extremity. Its pre-debridement measurement is 1.3 x 1.3 x 0.2. Its post-debridement measurement is 1.3 x 1.3 x 0.3. The appearance of the wound shows that there is a large amount of yellow fibrinous slough overlying some healthy granulation tissue. We have taken a 4 mm curette and curetted away all of this yellow fibrinous debris until we get down to some nice, healthy granulation tissue in the subcutaneous tissue space. The wound was anesthetized with 1% lidocaine injected into the wound area as well as some topical Hurricaine spray. The bleeding was controlled with simple pressure to the wound. The wound was covered with a Prisma dressing with his Jobst stocking put back into place. The patient tolerated the procedure well.

The next procedure is on ulcer #2. It is an excisional debridement. The location of the wound is the right medial extremity just proximal to ulcer #1. Its pre-debridement measurement is 1.0 x 1.0 x 0.2. Its post-debridement measurement is 1.0 x 1.0 x 0.3. The appearance of the wound shows a large amount of yellow fibrinous slough in the wound base obscuring any healthy granulation tissue at all. We have taken a 4 mm curette and curetted away this yellow fibrinous slough until we got down to nice, healthy granulation tissue in the subcutaneous tissue level. Bleeding was controlled with simple pressure to the wound. The wound was anesthetized with lidocaine 1% injected into the wound with Hurricaine spray put topically over the wound. Prisma was placed into the wound with the Jobst stockings put back in place. The patient tolerated the procedure well without any difficulties.

The next procedure is on ulcer #3. Ulcer #3 is located in the left lateral leg. It is an excisional debridement. The pre-debridement measurement is 1.1 x 0.9 x 0.3. The post-debridement measurement is 1.1 x 0.9 x 0.4. The appearance of the wound shows a large amount of yellow fibrinous necrotic material overlying the wound base so that there is no ability to appreciate any granulation tissue in that wound base. We have taken a 4 mm curette and curetted away this yellow fibrinous necrotic material until we got down to some nice, healthy granulation tissue in the subcutaneous tissue level. Bleeding was controlled with simple pressure to the wound. We have used lidocaine 1% injected into the wound as well as topical Hurricaine spray for anesthesia. Prisma was placed into the wound with his Jobst stockings put in place over that. The patient tolerated the procedure well.

ASSESSMENT AND PLAN: The patient has marked edema of his bilateral lower extremities with the vascular surgeons giving him a diagnosis of venous insufficiency, which they believe to be stage VI. Their plan is to follow him up in two months at which time they will repeat a venous duplex study to see if there is a possibility of intervention that may be helpful for his symptoms. In the meantime, we are going to continue compression with his Jobst stockings. We have asked him to elevate his extremities when he is sitting down. He is trying to take in good nutrition to help heal these wounds. He is to try and keep his diabetes under control for helping with wound healing. We will plan on seeing him back here in one week for further evaluation and treatment of his venous insufficiency disease.