Ortho SOAP Note Medical Transcription Samples

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is seen in followup regarding his right knee injury. He is approximately three months status post right quadriceps tendon repair. He has been wearing a hinged knee brace, which has been unlocked. He has been receiving outpatient physical therapy. At the present time, overall, he is doing quite well. He has no pain.

OBJECTIVE:  On examination of the right knee, the skin is examined. The skin is intact. Surgical incision is well healed. There is no knee effusion. There is no soft tissue swelling. The foot is warm and well perfused with brisk capillary refill. Motor and sensory functions are intact distally. Passive range of motion is from full extension to 135 degrees of knee flexion. Arc motion is pain-free. The knee is stable to varus valgus stress testing. There is mild quadriceps muscle atrophy. His gait is examined. It is nonantalgic in nature.

ASSESSMENT AND PLAN:  Right quadriceps tendon rupture. The diagnosis was reviewed in detail with the patient. At the present time, overall, he is doing quite well clinically. We will discontinue the hinged knee brace. He will continue with outpatient physical therapy to work on range of motion and strengthening exercises as well as endurance. He is allowed to return to work, light duty, no heavy lifting. He will need frequent rest periods. We will see him back in three months’ time for repeat clinical evaluation. No x-rays needed at that time.

———————————-

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient returns. This is a gentleman who underwent a decompression and instrumented fusion of L3-L5. He is very satisfied with the result, seemed to have done well in terms of relieving his leg pain. He has developed an underlying lymphoma. He is being treated for that with chemotherapy. He is getting flare-ups of back pain, seems to be localized to his back, does not seem to radiate down his legs. No numbness or tingling in his toes. This has become bothersome to him. It waxes and wanes. When it bothers him, he rests. He is not sure what brings it on and what makes it better.

OBJECTIVE:  On exam, he stands with a level pelvis, is compensated. The paraspinal musculature is soft. When asked to forward flex, could do so cleanly to 70-80 degrees, side bend 10-20, extend 10. Trendelenburg sign is negative. Heel toe gait is preserved. Lower extremity motor is 5/5 throughout. Reflexes at knees and ankles are trace at the knees, 1+ at the ankles. Sensation is diminished across both feet, that is he cannot tell sharp from dull.

ASSESSMENT AND PLAN:  We think he has got a neuropathy. We will obtain new radiographs and review them. We have given him Robaxin for pain at his request. He is advised regarding the side effects. We will see how he fares.

———————————-

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is here for followup of her left knee. She has got some significant patellofemoral arthrosis. Also has some tricompartmental arthritis seen on an arthroscopy. It has really curtailed her activities. She inquired about Synvisc-One injection. We have gotten approval for that.

OBJECTIVE:  There is just a trace effusion today. She has got moderate patellofemoral crepitus, 0 to about 120. Positive flexion pain. Collaterals intact. Neurovascularly intact.

New x-rays were obtained today and compared to films from about a year and a half ago showing a mild progression of osteoarthritic changes in the patellofemoral joint in particular, but also slightly more so medially.

ASSESSMENT AND PLAN:  Knee osteoarthritis. Discussed treatment options. She wants to go forward with the Synvisc-One shot. We discussed risks, including but not limited to infection and adverse reaction to the Synvisc. She expressed good understanding and requested that it be done.

The left knee was prepped sterilely with Betadine and alcohol. Superolateral portal site was used to enter the knee under sterile technique with a 20-gauge needle injecting 6 mL of Synvisc. She tolerated it well.

We will see her back p.r.n. We discussed the possibility of the knee arthroplasty if this does not help her sufficiently.

———————————-

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient returns to Orthopedic Clinic today for followup evaluation of left shoulder partial infraspinatus and anterior labral tear. She is doing very well. She has been doing physical therapy since I last saw her, and her pain is completely resolved. She also reports she feels much stronger.

OBJECTIVE:  On examination today, she has full range of motion of the left shoulder. Negative Hawkins, Neer, cross-arm. Symmetric 5/5 strength on resisted internal and external rotation, thumbs down, supraspinatus, and lift-off testing.

ASSESSMENT:  Clinically improved left rotator cuff impingement and pain.

PLAN:  At this point, we have told her to progress gradually to a gym program. She can give me a call if her pain were to return, but we did recommend one Aleve by mouth twice daily and then to give us a call if she would have any worsening pain. We do not anticipate that her rotator cuff tear will progress to a full-thickness tear; however, once again, if she were to have any return of pain, she should come and see me immediately.

———————————-

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is here followup on her ankle sprain. She really has no pain. She has been working on her balance exercises, and this has made a big difference for her.

OBJECTIVE:  Her drawer sign is negative. She has no tenderness over ATFL and medial ligamentous complex. She does have a punctate area of numbness around the level of the medial talonavicular joint. This makes sense based on her mechanism of injury and showed her foot was stepped on.

ASSESSMENT AND PLAN:  The patient has made excellent recovery from her right ankle sprain. We have advanced her into full activities, and we will follow up with her on an as-needed basis.

———————————-

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient presents in followup regarding his orthopedic injuries. He is approximately four weeks status post right and left quadriceps tendon repairs. He has been in hinged knee braces locked in extension. He is to weight bear as tolerated. His wounds have healed. Overall, he is doing quite well. He is at a rehabilitation facility.

OBJECTIVE:  On examination of the right and left lower extremities, the wounds are healed. There are no local signs of infection. There is no soft tissue swelling, ecchymosis, or edema. There is bilateral quadriceps muscle atrophy. There is no calf pain, swelling or tenderness to palpation. He is able to perform straight leg raises against gravity bilaterally. Passive range of motion is from full extension to approximately 45 degrees of flexion on both sides. Radiographs were not performed today.

ASSESSMENT AND PLAN: Five weeks status post right and left quadriceps tendon repairs. The diagnosis was described in detail to the patient. At the present time, his knee braces can be unlocked. He will continue to weight bear as tolerated, and we will have the therapist begin to work on active range of motion, active assisted range of motion, passive range of motion, and progressive resistive exercises. We would like to see him back in five weeks’ time for repeat clinical evaluation. No x-rays will be needed at that time.

Ortho Operative Sample Reports

———————————-

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient describes the ability to basically subluxate both of his shoulders, although it is not painful. However, recently, it has started to hurt. He denies any other issues. He is right-hand dominant.

OBJECTIVE:  He is a well-nourished, well-developed male, in no acute distress. Normal affect. Skin is intact. He has a good range of motion, symmetric; about 185 degrees of forward elevation, external rotation to 60. Internal rotation is a little bit less on the right than the left to the low thoracic and midthoracic spine. He had a little bit of winging of the scapula. He has a negative O’Brien and negative dynamic labral shear. He has a little bit of a click with load and shift anteriorly, but he does not feel it, and he does not have any pain. He has negative apprehension and negative Jobe test. He otherwise is neurovascularly intact.

X-rays are negative.

ASSESSMENT AND PLAN:  At this point, we are going to get him into a formal physical therapy program. We spent a good time talking about his shoulder. We went over the sleeper stretch and other exercises. We talked about avoiding things that aggravate it. Certainly, if he has recurrent subluxations or any dislocations, we will go ahead and get an MR arthrogram. For now, we will get him into therapy. We will see him back in a month for a recheck. He will call in the interim with any troubles.

wordpress visitors