REFERRING PHYSICIAN: John Doe, MD

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female seen in consultation regarding possibility of vasculitis. She was admitted with cough and shortness of breath. Her problems began one day after she delivered a baby. The next day, she developed red lesions on the left side; these became palpable and raised. She has a picture on her cell phone where the lesions look a bit like isolated erythema nodosum. The lesions eventually turned into blood blisters and then ulcers. There are currently two lesions on the left side, on the lip and neck.

The patient saw her internist and saw Rheumatology, who did labs. The patient recalls being told that she had a positive rheumatoid factor, but she did not know what other labs were drawn. She was told she had a nonspecific vasculitis and started on 60 mg of prednisone. This was two weeks ago. Beginning the next day, she developed her cough and dyspnea. This progressively worsened to the point where she could barely breathe, and she came to the ER and was admitted.

She has a headache, but this is only related to her cough. She does note small amounts of hemoptysis. She has no sinus blood. She notes no change in her vision or hearing and has no ocular inflammation or stomatitis. She denies alopecia. She has no chest pain other than that associated with coughing, and she has no abdominal pain or diarrhea.

She has lost weight and is currently 15 pounds less than her prepregnancy weight. She has no focal or proximal weakness and no paraesthesias. She never had a malar rash or photosensitivity. She has not experienced Raynaud phenomenon. She has been on 60 mg of prednisone since two weeks ago and was admitted on that dose.

PAST MEDICAL HISTORY: Notable for questionable gestational diabetes, a motorcycle accident in the past with skull fracture and small CNS bleed. She has no history of peptic ulcer, chronic kidney disease, asthma, seizures, anemia or pleurisy.

CURRENT MEDICATIONS: Flexeril, omeprazole, Lovenox, azithromycin, meropenem, prednisone 20 t.i.d. was decreased to 20 b.i.d. last night, and fluconazole 400 mg IV daily was added. She is also on Vicodin and Dilaudid.

ALLERGIES: No known medical allergies.

FAMILY HISTORY: Father is alive and well. Mother is alive, status post myocardial infraction. There is no family history of rheumatoid arthritis or lupus.

SOCIAL HISTORY: The patient is married. She had a baby who died shortly postpartum and has one adopted son. Her three-month-old son is healthy. The patient does not smoke or drink, and she works at a computer.

LABORATORY DATA: CT scan of the chest showed miliary nodules. Followup CT scan showed progression of the nodule with some airspace opacity and small mediastinal lymph nodes. ANA is negative, sed rate is 90, CRP is 24, HIV is negative, INR is normal, albumin 2.2, globulin 5.3, ALT is 104, creatinine 0.8, H and H 10.4 and 32 with a white count of 25,000 and 292,000 platelets.

PHYSICAL EXAMINATION:
GENERAL: The patient had been afebrile until yesterday when she had a T-max of 101.6.
HEENT: No scleral or conjunctival inflammation. Oral mucosa is moist without lesions.
NECK: Supple without lymphadenopathy or thyromegaly. Carotid upstrokes are 2+, and there is no salivary gland swelling or tenderness.
LUNGS: Base greater than apex rales and rhonchi.
HEART: Tachycardic with heart rate of 134 but regular with no obvious murmur.
ABDOMEN: Nontender with no mass or organomegaly. Distal pulses are 2+.
NEUROLOGIC: Grossly intact, including intact strength.
SKIN: Notable for healing ulcers on the leg, two on the lateral left side with eschar. There are few small scattered pustules. The right lip has a healing eschar and the left neck has a healing eschar; otherwise, the skin is normal. Her joints are also normal with no synovitis, deformity or decreased range of motion.

ASSESSMENT AND PLAN: This is a (XX)-year-old female with a question of vasculitis. Her lesions seem a bit atypical for vasculitis but could represent a medium-vessel vasculitis. The patient also has pulmonary infiltrates but no renal inflammation, which would be expected with both granulomatosis with polyangiitis and microscopic polyangiitis to increase her immunosuppression.

We would require an open lung biopsy, but as of last night, Pulmonary canceled the pending open lung biopsy. Lowered the dose of prednisone and started fluconazole. There is also on the chart a printout regarding Cryptococcus gattii. It therefore seems that Pulmonary seems relatively certain that the patient is suffering from a fungal infection.

We will try and speak with Dr. Jane Doe as well as Rheumatology. We will also check antineutrophil cytoplasmic antibodies, urinalysis, cryoglobulins and hepatitis B and C.

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient returns for followup of rheumatoid arthritis and shoulder pain. For the shoulder pain, she has rotator cuff tear on the right and degenerative arthritis on the left. For the rheumatoid arthritis, she used to have pain and swelling at the MCPs, elbows, knees. Since we treated her with prednisone and leflunomide, those symptoms resolved. For the shoulder pain, we tried Lidoderm patch, but there was no significant improvement.

OBJECTIVE:  Normal appearance, in no acute distress. Vital Signs: Blood pressure 126/72, pulse 86. Heart: Irregular rhythm. Lungs: Clear with no wheeze or rub. Abdomen: No tenderness. Hand Exam: Shows puffiness of the MCPs, but no tenderness. Elbow Exam: Unremarkable. Shoulder Exam: Showed tenderness on range of motion on both sides. Knee Exam: No tenderness on range of motion.

ASSESSMENT AND PLAN:  The patient is here for followup of rheumatoid arthritis and shoulder pain. The rheumatoid arthritis is doing well with a combination of steroid and leflunomide. We will check the monitoring tests. We asked her to taper the prednisone to 50 mg daily for 2 weeks, then to 10 mg daily. For the shoulder pain, she did not respond significantly to the Lidoderm patch. We will add tramadol 100 mg b.i.d. to the treatment. We will see her for followup in a month.

Rheumatology SOAP Note Sample #2

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient comes in regarding followup. She has Raynaud’s and a positive antinuclear antibody. No heartburn or breathing symptoms. No hypertension. No lower extremity swelling, PND or orthopnea. She has some chronic arthralgia, which is improved by doing walking for exercise. She says, overall, she is feeling well.

OBJECTIVE:  On exam, her blood pressure was 112/62, heart rate 66, 2/10 pain in her neck and shoulders. She has some thickening and waxiness of the skin of her fingers between her PIPs and DIPs in all of her hands. No active Raynaud’s in the office today in her hands or feet. No cutaneous ulcerations. No oral ulcers or alopecia. She is tanned and looks well. Lungs are clear. Regular rate and rhythm. S1, S2. Upper extremity strength 5/5. Extraocular movements are intact. Pupils are equal, round and reactive to light and accommodation. No abnormal skin texture on her torso or face. Cranial nerves II through XII are intact.

ASSESSMENT AND PLAN:  Possible limited scleroderma manifested by Raynaud’s, very mild sclerodactyly and an ANA in an anticentromere pattern. Her Raynaud’s is quiescent given the warm weather. She will continue on her current behavior modification. She is not having active heartburn or any pulmonary symptoms. Her blood pressure is well controlled. Her skin texture is not a problem. Her arthralgia has gotten better with exercise. In regards to her allergies, we will give her a prescription for Allegra.

Rheumatology SOAP Note Sample #3

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  This is a followup visit regarding rheumatoid arthritis. The patient has no joint complaints today. She is feeling well. She presented with stiffness and puffiness in the PIPs, MCPs, and ankles. She is seronegative. Her CRP was 18. She was started on 10 of prednisone and did well and was weaned on to methotrexate. She has had no real RA symptoms since then. She denies any oral ulcers, abdominal pain, nausea, vomiting or diarrhea. No fevers, chills, or shortness of breath. No alopecia or oral ulcers.

OBJECTIVE:  On exam, she has no synovitis in small joints of the hands or wrists. Normal range of motion of all joints and no swelling or tenderness in the joints of the feet. She has 5/5 upper and lower extremity strength. No swelling of any joints. No knee effusions. She is tanned without any overt alopecia or oral ulcers.

ASSESSMENT AND PLAN:  Rheumatoid arthritis, seronegative, doing well. We are going to order a musculoskeletal ultrasound for monitoring to make sure our clinical impression is correct and that she is adequately controlled on monotherapy of 7 tablets once a week. We have given her a prescription for outside labs given the distance. She checks them and requested them sent to us. She has been very compliant.

Rheumatology SOAP Note Sample #4

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  This (XX)-year-old female reports having pain in her bilateral shoulders, bilateral neck, hips and buttocks, worse at night when she tries to sleep and in the morning hard to get out of bed, off the toilet seat, very stiff and uncomfortable. She has tried Aleve without any benefit. No headache, vision changes, upper and lower extremity or jaw claudication. She has had a history of Lyme disease but was treated in the past, was checked for Lyme during this episode without any benefit. No hand or foot swelling. She did have a traumatic injury to her right index finger and she has a slight contracture at it. Past medical history otherwise is notable for some mild early hypertension and glaucoma. She uses brimonidine tartrate, Cosopt and also takes lisinopril.

OBJECTIVE:  Vital Signs: Blood pressure 170/98 with a heart rate of 120, 96-98% on room air. She has decreased range of motion in her shoulders and neck. Difficulty getting up the chair onto the exam table without using her arms. No synovitis in small joints of the hands or wrist. Temporal arteries are nontender. Lungs are clear. Heart: Regular rate and rhythm. S1, S2. No murmurs or gallops. Upper and lower extremity strength, 5/5. Abdomen is soft and nontender. Moist mucous membranes. No clubbing, cyanosis, or edema.

She has had a negative rheumatoid factor, negative Lyme test, normal thyroid test, and ANA negative.

ASSESSMENT AND PLAN:  We suspect she has polymyalgia rheumatica. Given the history of glaucoma, we are going to start her with 10 mg of prednisone. We have given her a handout regarding polymyalgia rheumatica and stressed the importance of letting the office know if she develops any symptoms consistent with giant cell arteritis. She will have a CRP done today with anti-CCP antibody, SPEP, UPEP, and immunofixation. She will call us. If she is getting clinical benefit, then we will continue on this regimen, 10 mg for a month, and come back in a month.

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