Orthopedic SOAP Note Medical Transcription Example

SUBJECTIVE:  The patient is a (XX)-year-old seen for right shoulder pain. He has had a rather insidious onset of pain a month ago. He complains of pain with the ends of forward flexion and abduction. He has noticed a loss of motion. He has had difficulty reaching overhead. He has had problems sleeping. He had no particular injury that he can recall. He complains of pain over the lateral deltoid area primarily. He rates the pain as 7/10 today.

OBJECTIVE:  The patient is a well-appearing gentleman. He appears well. He is 5 feet 8 inches, 204 pounds. He is walking with a normal gait. He has got full symmetrical motion of his neck and a straight spine. He has got no pain to palpation of his neck. No pain to palpation about his posterior shoulder musculature. No atrophy noted about the shoulder girdle. His range of motion is limited significantly. Abduction is only about 70 degrees actively. Passively, I can get him to about 90, significant pain with that. Forward flexion is about 110-130 with moderate pain. Internal rotation limited to his belt. He is able to do a lift-off. His left side is 5/5. His external rotation and supraspinatus are 5/5 bilaterally; although, he has significant pain with both, particularly supraspinatus, on the right. Speed’s test causes him some mild pain. AC joint is prominent but nontender. He is neurovascularly intact distally. No swelling of his arm noted.

X-rays obtained today show some significant degenerative arthritis of the AC joint. Type II acromion. Well-maintained glenohumeral and subacromial spaces.

ASSESSMENT AND PLAN:  Rotator cuff tendinopathy and nascent adhesive capsulitis. He is having rather significant pain. He is unable to take NSAIDs because of the Coumadin. We talked about doing a corticosteroid injection today. We talked about the risks of bleed in conjunction with his INR of 3.3. His other risks, including but not limited to steroid flare and infection, were discussed as well. He requested that the injection be done. The risk of the bleed was minimal. The posterior aspect of the right shoulder was prepped sterilely with Betadine and alcohol. Posterior portal site was used to enter the subacromial space under sterile technique with a 22 gauge needle injecting 60 mg of Kenalog, 1.5 mL of lidocaine. The patient tolerated it well. I am going to see the patient back in 6-8 weeks’ time. Gave him a home program to get working in terms of motion. We talked about a formal physical therapy consult. The patient would rather work on his own for now. I will see him back in 6-8 weeks.

Rehab SOAP Note

SUBJECTIVE:  This is a (XX)-year-old female who is being followed for left hip pain. She has a history of a right hip arthroscopy in the past. We are following her for some time now for a left hip with similar problems. She has some mechanical symptoms of catching, popping, and groin pain. We saw her couple of months ago where she had left knee pain. We did an injection on the left knee. In the last couple of weeks, she also had a fall at work and had pain in the right knee. She had x-rays of her spine, hip and knee with no changes in x-ray. She did report some numbness and tingliness in her feet, on the right side, but this has all resolved. She is overall doing quite well on the right side. She is still having mechanical symptoms in the left with pain. Pain score today is 4/10.

OBJECTIVE:  On exam of the left hip, we can flex her up to about 90 degrees or so. She has a positive anterior impingement test. She has no pain with Faber test. She has about 10 degrees of internal rotation, about 30 degrees of external rotation. She can do straight leg raise without any difficulty. No numbness or tingliness in the foot. She is firing her hip flexors, hip abductors, and quad. The left knee has no swelling. There is some pain with palpation along the joint line, positive endpoints of varus valgus stress and anterior drawer. Some superficial skin abrasions, which are healing nicely. Skin is relatively intact. There is no erythema. No pain with palpation with the joint line or anterior posterior drawer and varus valgus stress. There are positive endpoints of varus valgus stress as well. She is firing her quad and hamstring, dorsiflexors, plantar flexors.

Radiographs of her spine do show some mild scoliosis with degenerative changes of lumbar spine. She has had prior surgery on her back. X-rays of her hip show mild arthritis in the right hip. On left hip, there are some signs of impingement with some sclerosis of the head-neck junction. She has a combination of pincer and cam-type femur. There is good joint space maintained. There is a little bit of narrowing in the inferior joint space.

ASSESSMENT AND PLAN: The patient still complains of persistent pain in the left hip. We do already have her scheduled for surgery. We have been following her for some time now. We went over the risks and benefits of surgery again. We explained to her that we would lean towards not doing the surgery, but she did have some significant relief of the right hip. We explained that she does seem to have a good joint space. She continues to be inhibited on a daily basis by this hip pain and would like to go forward. She will be scheduled for surgery.

SOAP Note Sample Reports

SUBJECTIVE:  The patient presents in followup regarding her right pelvic injury. She was seen in March of this year, referred by Dr. Doe for right-sided pelvic pain. A bone scan was performed, which was normal as were radiographs. An MRI demonstrated no evidence of pathologic processes, no evidence of stress fracture. Clinically, she appeared to have a traction apophysitis affecting the right iliac crest. Over the past 2 months, her symptoms have improved. She does have occasional pain located over the right iliac crest with prolonged walking; however, this has decreased since the last visit. She has no night pain. She has no pain at rest. She denies any groin pain, hip pain, thigh pain, trochanteric or buttock pain. She denies any altered sensation in the lower extremities. She denies any constitutional symptoms.

OBJECTIVE:  On examination of the pelvis and lower extremities, the skin is intact. Leg lengths are equal. There is no soft tissue swelling, ecchymosis or edema. There is tenderness to palpation over the trochanter on the right side. There is no pain with general passive range of motion of the right hip. Motor strength is 5/5 distally. There is tenderness to palpation over the anterior aspect of the right iliac crest; this is decreased since last visit. Her gait is examined, nonantalgic in nature.

ASSESSMENT AND PLAN:  Right iliac crest apophysitis. The diagnosis was described in detail to the patient. At the present time, clinically, she is improved. However, I do feel it would be prudent to have her follow up in 2 months for repeat clinical and radiograph evaluation with AP pelvis radiographs as well as Judet views of the right acetabulum. If there are any problems prior to the next appointment, she is instructed to give a call.

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