PROCEDURES PERFORMED:

1. Tilt table testing.
2. Carotid sinus massage.

OPERATOR:  John Doe, MD

REFERRING PHYSICIAN:  Jane Doe, MD

INDICATION FOR PROCEDURE:  Syncope.

FINDINGS:  Baseline sinus rhythm at 70 BPM with normal cardiac conduction intervals.

INDICATION:

1. PR interval equals 160 milliseconds.
2. QRS interval equals 80 milliseconds.
3. QT interval equals 360 milliseconds.
4. The patient was observed in a 70 degree head-up tilt position for a total of 30 minutes in a drug-free state, during which she remained asymptomatic with both stable blood pressure (BP equals 95-121/55-71) and heart rate (HR equals 75-112 BPM).
5. The patient continued to be observed in a 70 degree head-up tilt position for additional of 5-minute period of time following sublingual nitroglycerin (0.4 mg) administration, during which she developed progressive dizziness, fatigue, and diaphoresis (similar to clinical symptoms) prior to development of complete loss of consciousness associated with profound hypotension (BP equals 61/33) and inappropriate normocardia (HR equals 91 BPM). The patient awoke, returned to the supine (0 degrees) position.
6. No evidence for carotid signs of hypersensitivity with either right or left-sided carotid sinus massage.

COMPLICATIONS:  None.

IMPRESSION:

1. Neurocardiogenic syncope (mixed vasodepressor/cardiac inhibitory response).
2. No evidence for carotid sinus hypersensitivity.

RECOMMENDATION:  Consider a future empiric beta-blocker (Toprol XL 50 mg daily) therapy in place of current calcium channel blocker (verapamil 40 mg t.i.d.) for a combined management of retention and neurocardiogenic syncope.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old man, originally from (XX), with a history of tuberculosis and lymphatic infection 11 years ago for which he completed treatment, who presents to the emergency department with 2-3 weeks of diffuse pruritic maculopapular rash.

Rash initially involved both hands, including palm area and neck, progressing to diffuse body rash, sparing facial area.  The patient reports no previous similar events.  He has been in contact with fiberglass particles at his construction work and used new cloth detergent approximately 2 weeks ago, which coincides with development of rash.

Denies fevers, chills, nausea, vomiting, diarrhea, dysuria, night sweats, loss of weight, decreased appetite, respiratory symptoms, sick contacts or travel.

He received prednisone 60 mg x1 and Benadryl 25 mg x1 in the emergency department with good symptomatic relief.

REVIEW OF SYSTEMS:  All other components of review of systems are negative or as described in history of present illness.

PAST MEDICAL HISTORY:  Mycobacterial infection treated 11 years ago, right foot surgery for removal of an accidentally included wood piece.

FAMILY HISTORY:  Father died of complications of asthma.

SOCIAL HISTORY:  Born in (XX), immigrated to the United States 7 years ago.  Lives in (XX).  Construction worker.  Denies drug, tobacco or alcohol use.  He is not sexually active.  Last sexual partner was approximately 2 years ago.  Reports consistent use of condoms.  No prior HIV test.  Vaccinations are up-to-date.

ALLERGIES:  No known drug or food allergies.

MEDICATIONS:  Prednisone 60 mg p.o. x1, Benadryl 25 mg p.o. x1.

PHYSICAL EXAMINATION:

GENERAL APPEARANCE:  Thin man, resting comfortably in bed, in no acute distress.

VITAL SIGNS:  Blood pressure 124/82, heart rate 60, respiratory rate 18, temperature 97.6 and pulse oximetry 100% on room air.

EYES:  No icterus.  Pink conjunctivae without petechia.

ENT:  Clear tympanic membranes and nasal turbinates and oropharynx.

NECK:  Bilateral neck fullness.  Supple.

LUNGS:  Clear to auscultation bilaterally.

HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.

ABDOMEN:  Nondistended, bowel sounds present, nontender and soft.  No organomegaly.

GENITOURINARY:  No open lesions.  Normal sized penis and testes.  No ureteral discharge.

LYMPH:  No neck, supraclavicular or axillary lymphadenopathy.

BACK:  No pain on palpation of vertebral processes or costovertebral angles.

MUSCULOSKELETAL:  No joint effusion, warmth.  Full range of motion throughout.

VASCULAR:  2+ throughout.

SKIN:  Dry skin with diffuse maculopapular rash and excoriation, sparing face.  No open lesions, ulcerations, scaling skin or discharge.

NEUROLOGICAL:  No gross neurological deficits.

PSYCHIATRIC:  Alert and active.  Appropriate.

LABORATORY DATA:  Sodium 131, potassium 3.8, chloride 102, CO2 31, anion gap 6, glucose 79, BUN 11, creatinine 0.89, calcium 9.0.  Total bilirubin is 0.5, AST 33, ALT 26, troponin 0.01, LDH 339, amylase 106.  WBC 3.1, hemoglobin 15.7, hematocrit 45.4, platelet 170,000, segmented cells 43, bands 2, lymphocytes 25, reactive lymphocytes 2 and eosinophils 17.

ASSESSMENT AND PLAN:  This is a (XX)-year-old gentleman with 2-3 weeks of diffuse erythematous maculopapular rash with facial sparing.  After carefully obtaining detailed history, he seems to have clear exposure to possible offending agents, including fiberglass, new detergent and possibly bed bugs.  Rash is consistent with an allergic dermatitis rather than an infectious process.  Although involvement of palms and soles can be seen in certain infectious process as syphilis and viral syndrome, we think history is more consistent with allergic reaction, which is supported by the presence of elevated eosinophils.  We think main therapy would consist of remove offending agents along with the application of topical steroid cream and antihistaminic therapy for symptomatic relief.  We agreed with RPR for evaluation of syphilis.

RECOMMENDATIONS:

1. Obtain RPR – syphilis IgE.
2. Remove offending agents.
3. Topical steroid cream and antihistaminic.
4. Follow up with primary care or Dermatology if no improvement in 1 week.

Thank you for this consultation.  Please contact infectious disease team if any questions or changes in the patient’s clinical status. Recommendations discussed with the emergency department team and handwritten note placed in the patient’s medical records.

SUBJECTIVE: The patient is here today with increasing symptoms of his asthma over the past week. He has had no fever. His chest is tighter and his Symbicort is not working. He is using his Ventolin inhaler more frequently.

His past medical history includes asthma, gastroesophageal reflux disease and allergies.

OBJECTIVE: Temperature is 98.4. HEENT: Unremarkable. Neck: Supple without adenopathy or thyromegaly. Lungs: Reveal diffuse wheezes bilaterally. Heart: Regular.

ASSESSMENT: Asthmatic bronchitis.

PLAN: The patient is given prednisone 50 mg to 0 mg taper. He is also given albuterol for nebulizer 4 times a day. We will cover him with antibiotic Zithromax 500 mg once a day for 5 days. The patient will follow up p.r.n. no improvement in his symptoms.

SOAP Note Example Medical Report #2

SUBJECTIVE: This (XX)-year-old patient of Dr. Jane Doe has had pain and a small amount of discharge in the right ear for the last 3 days. She teaches swim lessons and is in the pool all day. There has been no sore throat, cough, cold or coryza. She does not use Q-tips.

OBJECTIVE: Well woman in no obvious discomfort. Minimal irritation without erythema in the right ear canal. The left ear canal is normal. Both tympanic membranes are normal. The pharynx is perfectly clear.

ASSESSMENT: Early otitis externa.

PLAN: Cortisporin Otic solution 3 times a day. Return if not improved.

SOAP Note Example Medical Report #3

SUBJECTIVE: This (XX)-year-old patient of Dr. John Doe has chronic venous insufficiency. He occasionally wears support hose. Last night, he noticed that his left lower extremity was getting red. He has an area of skin breakdown, apparently an abrasion on the lateral margin. There has been no fever or chills. He was on cephalexin for 10 days last year for a similar problem.

OBJECTIVE: Thin gentleman in no apparent discomfort. Temperature is 98.6. The left lower extremity is red, minimal tenderness from knee to ankle.

ASSESSMENT: Cellulitis.

PLAN: We advised ceftriaxone 1 gram IV now. We will start cephalexin 500 mg 4 times a day. We have asked him to apply moist heat to lower extremity tomorrow. Return for reevaluation in the walk-in.

SOAP Note Example Medical Report #4

SUBJECTIVE: The patient is complaining of some intermittent dizziness off and on over the past 4 or 5 months. She was evaluated by somebody at work who thought she had benign positional vertigo and treated her with Antivert. It worked well, but when she stopped taking it, some of the symptoms recurred. She describes a dizzy feeling, primarily with putting her head back but not with any other movements. She has recently developed some tinnitus, which she described as a buzzing noise in her ear. Again, it is intermittent. Her hearing has been okay with no changes noted. She has not been unable to drive, and the symptoms have not interfered with her daily routine.

OBJECTIVE: Blood pressure 122/84, pulse 74 and regular, weight 142. Ears: Canals are clear. TMs are somewhat dull with absent light reflex. Throat: Clear. No exudate or erythema. No lateral banding. Neck: Supple. No increased adenopathy. Chest: Clear to P and A. No rales, rhonchi or wheezes.

ASSESSMENT: Benign positional vertigo.

PLAN: We have told her to use the Antivert on a p.r.n. basis. She also has serous otitis media, and we instructed her in pushing fluids and doing Valsalva. This may very well improve her dizziness somewhat. She also has some intermittent edema in her feet and says that her hands and feet are always cold. On exam, she does have a little purplish color to her distal feet and toes and they do feel cool.

SOAP Note Example Medical Report #5

SUBJECTIVE:  The patient is here today complaining of having had her period 3 times in the last 4 weeks. She said that they are not specifically heavier, but she has only 1 or 2 days where it is heavy and then the next day it is only a little brownish discharge. She normally has very regular period, and her period will last about 5 days with mild cramping. She denies any unprotected intercourse. She always uses protection. She denies any breast tenderness. She never had missed any either.

OBJECTIVE:  In terms of her exam today, her blood pressure was 114/66, which is about the same for her as before. Heart rate was 66. She weighs 136 pounds. Her temperature is 98.4. Her thyroid exam showed that she has normal thyroid. We could not feel for any masses. She does not have any upper extremity tremor either. Her lung examination was clear. Her cardiac examination showed regular heart sounds. She has no S3 or S4. Conjunctival exam is normal. Eye exam is EOMI and PERRLA. Abdominal examination showed a soft abdomen. She has no hepatomegaly. No splenomegaly.

ASSESSMENT AND PLAN:  This is a lady who is here today for menorrhagia. She is (XX) years old. Her symptoms might be related to perimenopause. However, we decided to check her CBC but also to check her thyroid. We explained to her that both hyper and hypothyroidism may cause her symptoms; although, she denies any change in her weight, any agitation or any fatigue. We will then follow up on her lab results, and we also discussed today perimenopausal symptoms.

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.

DATE OF INDEPENDENT MEDICAL EXAMINATION (IME):  MM/DD/YYYY

LOCATION OF INDEPENDENT MEDICAL EXAMINATION (IME):  XYZ

INTRODUCTION: The claimant was informed that this independent medical examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by the claims manager, and was not intended as a general medical examination.

The claimant was asked at the time of the examination not to engage in any physical maneuvers beyond what she was able to tolerate or which she believed were beyond her limits or which could cause harm or injury.

The examinee was instructed that the evaluation could be stopped at any time and not to allow the evaluation to continue if it caused pain.

HISTORY OF PRESENT COMPLAINT: She confirms she was involved in a motor vehicle accident on MM/DD/YYYY. She was reportedly stopped at a pedestrian crosswalk, at which point she was rear-ended by a vehicle that she quantifies as traveling about 45 miles per hour. She was seat-belted. There was no airbag deployment. She did strike the headrest upon recall but did not have any closed head injury to the frontal aspect of her head and denies any loss of consciousness.

Reportedly, it was a hit-and-run, the vehicle began to take-off, at which point she pursued the vehicle. She reports the vehicle then stopped and she had a conversation, at which point she informed the person that she would call the police if they fled; however, they did.

She, therefore, filed a police report, but she has no information as to whether the person was subsequently apprehended. The vehicle was therefore able to be driven.

Subsequent to the motor vehicle accident, the following day, she began to pursue chiropractics. She reports that she pursued this particular chiropractor based on a pamphlet that was at her insurance company that she found.

She then began treatment the following day. Initial treatment consisted of x-rays of her various areas of discomfort as well as the initiation of treatments consisting of components of therapeutic exercises, adjustments and massage.

She reports, over the course of the first week, she was seen on an everyday basis and has progressively lessened; however, she continued to be seen on a three-times-per-week basis utilizing two visits for massage therapy and one for some component of adjustments and strength work. Her last visit was yesterday.

She is also four months’ pregnant currently and therefore reports that she had less visits secondary to this pregnancy and also less participation in the treatments. She had no surgery on her low back. She had no injections or formal physical therapy or acupuncture since the accident.

CHIEF COMPLAINTS/ CURRENT CONDITION: Chief complaints currently are as following:
1. Headache.
2. Left-sided neck and upper back pain.
3. Left arm pain.
4. Left lower back pain.
5. Left thigh pain.
6. Left knee pain.

In terms of her current condition, she has pain on an everyday basis. She quantifies the pain overall at 6/10 with division of the headaches at 4/10, the low back at 6/10 and the shoulder or upper back issues at 6/10. She describes the headaches on an everyday basis typically occurring in the left occipital area with some associated nausea and photophobia.

She also describes left-sided neck and upper back issues, not really in the glenohumeral area, but more in the upper trapezial area. This overall has about 50% improvement.

She describes some radiation of symptoms down into her left upper extremity, both in the anterior and posterior aspects, which she describes as burning, paresthetic and numb.

Additionally, she has continued left-sided low back pain, which causes some radiation of pain into her anterior and posterior thigh. Overall, she reports the low back has improved by about 25%.

She has no symptoms distal to her knee but also describes pain specifically in the knee, more in the anterior and lateral aspects. This reportedly increases with ambulation.

Again, in terms of her left upper extremity, she has symptoms that extend to just distal to the elbow, but she reports that they encompass the entirety of the upper arm. She has no bowel or bladder complaints.

CURRENT WORK STATUS: In terms of current work status, she has been completely off of work since the accident.

PAST MEDICAL HISTORY:

Injuries: She reports a work-related low back injury secondary to lifting some bedspreads in (YYYY). She underwent a course of massage and physical therapy and after about two months had resolution of symptoms. She reports at the time of this accident, she was asymptomatic in terms of back, neck or extremity issues.

Prior trauma consists simply of the back injury as previously mentioned.

Time loss/work comp claims include the above mentioned back injury.

Conditions: General Medical History: None.

Operations: Ovarian cyst surgery.

Allergies: Penicillin.

Current Medications: Vitamins and fish oil.

Substance Use:

Tobacco: She does not smoke.

Alcohol: She does not drink.

SOCIOECONOMIC HISTORY:

Marital Status: She is married with two children and is currently pregnant.

Education: She has primary education.

Military Service: She has no military history.

Hobbies: Gardening and walking.

REVIEW OF SYSTEMS: Positive for the before-mentioned headaches, neck, upper back, mid back, low back and left-sided upper and lower extremity pain. She has no psychiatric history.

RECORD REVIEW: Review of medical records begins with a cover letter discussing a date of injury of MM/DD/YYYY.

Subsequent to this, there is initiation of chiropractic treatment on MM/DD/YYYY. There were x-rays performed on that day, including a cervical spine x-ray, which demonstrated no acute findings as well as a lumbar spine x-ray, which demonstrated some decreased L5-S1 height. There is also a left shoulder x-ray, which demonstrates some AC joint widening without any other obvious findings; a left knee x-ray, which is normal; and a left ankle x-ray, which is normal.

She was complaining of a combination of neck pain, mid back pain, low back pain, left-sided shoulder and hip issues as well as left knee and left ankle.

She continued treatments until MM/DD/YYYY and then on MM/DD/YYYY was seen for reevaluation noting left upper back was her worst complaint.

She continued treatments with the chiropractic center from MM/DD/YYYY to MM/DD/YYYY and on MM/DD/YYYY underwent an MRI of her cervical spine, which demonstrated some mild left-sided protrusion at T4-5.

On MM/DD/YYYY, she was seen by a provider for an evaluation. This was for a combination of neck pain, mid back pain, low back pain, left knee pain, left arm pain, and left shoulder pain. Treatment recommendations at that time were a Medrol Dosepak as well as medications for symptomatic treatment as well as continued mobilization. Recommendation was also MRI of the shoulder if she continued having problems. Again, subsequent to this, then she continued chiropractic treatment from MM/DD/YYYY to MM/DD/YYYY.

She saw the provider again on MM/DD/YYYY, noting some improvement in her pain. Recommendation was continued chiropractic therapy as well as time off work until MM/DD/YYYY. Recommended was MRI of the left shoulder.

There is then the MRI of her cervical spine on MM/DD/YYYY. Again, this demonstrated mild left paracentral disc protrusion at T4-5. There was no evidence of disc protrusion, stenosis or spinal cord impingement. There was no evidence of disc space narrowing.

Chiropractic treatments then continued between MM/DD/YYYY and MM/DD/YYYY.

There are then miscellaneous wage calculations as well as bills; estimation of damage to the vehicle, which appears to about $1400, and photos, which demonstrated some mild driver rear aspect vehicle damage. Again, these photos are somewhat suboptimal in quality.

IME PHYSICAL EXAMINATION

The claimant is right-hand dominant.

Age: (XX) years
Height: 5 feet 6 inches
Weight: 148 pounds

In terms of physical examination, she is a pleasant female who appears in no distress currently.

Evaluation of her cervical spine demonstrates essentially tenderness in the left paraspinal musculature throughout the cervical spine. There are no spasms or soft tissue swelling, and she has no midline step-off deformities.

She then has global discomfort in the left paraspinal musculature essentially from the upper thoracic spine all the way down to the S1 level. Nowhere within this span are there any spasms or soft tissue swelling. She also has discomfort in the upper trapezius and medial scapula on the left side, again without spasms or soft tissue swelling.

In terms of her lumbar spine:

Motor Exam: In upper extremities, she has symmetric 5/5 strength in her deltoid, biceps, triceps, wrist flexors, wrist extensors, FPL, EPL, and interossei; although, essentially any resistance on the left upper extremity caused her discomfort both in the combination of her neck and shoulder area.

In the lower extremities, she has 5/5 symmetric strength in her iliopsoas, quadriceps, hamstrings, gastroc-soleus, tibialis anterior and peroneals with again discomfort during any kind of resistance of her left lower extremity.

She is intact to light touch from C5 to C8 bilaterally and also from L2 to S1. She has symmetric 2+ brachioradialis, biceps, triceps, patellar and Achilles reflexes. She has a normal gait. She has some subjective decreased sensation in the left middle finger and ring finger, but again she is intact to light touch.

She has palpable tenderness along the posterior aspect of her right shoulder as well as in the anterior glenohumeral joint. She has some mild discomfort with passive manipulation of her glenohumeral joint and also with resisted supraspinatus.

Examination of her knees demonstrates:

She has anterior discomfort palpably in the left knee along the patella tendon and also along the lateral joint line. She has a negative McMurray’s test. She has a stable knee in terms of a negative Lachman’s, posterior drawer and no evidence of varus or valgus laxity.

DIAGNOSTIC STUDIES: None were submitted for review.

IME DIAGNOSES AND RELATIONSHIP:

1. Cervicothoracic strain with headaches, secondary to motor vehicle accident of MM/DD/YYYY.

2. Thoracic strain, related to motor vehicle accident of MM/DD/YYYY.

3. Lumbosacral strain, related to motor vehicle accident of MM/DD/YYYY.

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.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES: Chronic otitis media with hearing loss and chronic adenoiditis.

POSTOPERATIVE DIAGNOSES: Chronic otitis media with hearing loss and chronic adenoiditis.

PROCEDURES PERFORMED:
1. Adenoidectomy.
2. Bilateral myringotomy and tube.

ANESTHESIA: General.

BLOOD LOSS: Not significant.

DESCRIPTION OF PROCEDURE: The patient was placed on the operating table and given mask induction without problems. The IV was started. The patient was intubated. The operating microscope was brought into position. The right ear was examined.

An anterior-superior quadrant myringotomy incision was made and thick fluid was suctioned from the middle ear space. An Activent tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal.

A similar procedure was undertaken on the left side. The ear was cleaned of cerumen. An anterior-superior quadrant myringotomy incision was made and thick fluid was suctioned from the middle ear space. The same type of tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal.

The bed was turned 90 degrees. The McIvor mouth gag was placed in the oral cavity with a #2 blade. There was crusted purulent mucus in the nasal cavity. Culture of the nasopharynx was performed. The red rubber catheters were used to retract the palate.

Adenoids were moderately hypertrophic. Adenoid tissue was removed with the Coblation wand with a setting of 6 and 5 and suction Bovie cauterization was used to control bleeding. Intravenous Decadron was given at the start of the procedure.

The pharynx was irrigated and suctioned. The patient tolerated the procedure well. He was discharged to home on Augmentin, Orapred, Ciprodex and Tylenol or Motrin. Followup in the office will be within the next two weeks.

Myringotomy and Tube Medical Transcription Operative Sample Report #2

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Chronic otitis media with hearing loss, left ear.

POSTOPERATIVE DIAGNOSIS: Chronic otitis media with hearing loss, left ear.

PROCEDURE PERFORMED: Left myringotomy and tube.

ANESTHESIA: General.

BLOOD LOSS: Not significant.

DESCRIPTION OF PROCEDURE: The patient was placed on the operating table and given intravenous induction without problems. She was mask ventilated. The left ear was examined with an operating microscope. There were signs of chronic otitis media with tympanic membrane tympanosclerosis.

The previously inserted Touma T-tube was removed and granulation tissue around the ostial opening of the tube was removed.

The incision was enlarged with a #7120 Beaver blade and the same type of Touma T-tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal. The patient will follow up in the office within the next 7 to 10 days. Water precautions are to be maintained. The patient is to finish her present course of Levaquin.

PREOPERATIVE DIAGNOSIS: Bunion, right great toe.

POSTOPERATIVE DIAGNOSIS: Bunion, right great toe.

OPERATION: Chevron bunionectomy, right great toe.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, PA

ANESTHESIA: General.

POSTOPERATIVE CONDITION: Satisfactory.

INDICATIONS FOR SURGERY: This patient had chevron bunionectomy on her left foot last year, did very well, and the right foot was resistant to all conservative measures and surgery was indicated.

DESCRIPTION OF PROCEDURE: With the patient under satisfactory general anesthesia, supine on the operating table, the right foot was prepped with DuraPrep and draped into a sterile field for Chevron bunionectomy.

After the proper surgical consent form, surgical site marking, surgical time-out and infusion of preoperative antibiotics were performed and documented, the right leg was elevated. The tourniquet was applied to a pressure of 350 mmHg.

Medial incision was made over the MP joint. Dissection was carried out down to the capsule. The capsule was entered through a V incision based proximally and retracted distally as the capsule was dissected off the metatarsal head.

The saw was used to perform a bunionectomy and chevron cut was made. The metatarsal head was displaced laterally 4 mm and secured with an absorbable K-wire.

The remaining part of the shaft that was around medially was then removed with the saw and a drill hole was placed through the metatarsal shaft.

The wound was irrigated and the toe was held in a few degrees of varus and plantarflexion, and the capsule was reattached to the drill hole with interrupted PDS suture. The PDS was used on the superior and inferior capsule to reinforce the suture line. Vicryl was used to reinforce that. Vicryl was used on the subcutaneous, and the skin was closed with nylon suture.

A splint was applied. A dry, sterile dressing was applied. The tourniquet was released and normal circulation was noted to return to the toes.

The patient was taken to the recovery room in satisfactory condition after the completion of the Chevron bunionectomy.

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.