OBJECTIVE:
VITAL SIGNS: Weight 12.6 kg, which is the 66th percentile. It is actually down half a pound since her last visit; however, mother does report that she refused to sit still and the scale was moving and it was hard to get an accurate read. Height 89.2 cm, 91st percentile; OFC 40.2 cm, 75th percentile; temperature 98.2 axillary. Stated pain level now is 0.
GENERAL: The patient is a well-developed, well-nourished female in no apparent distress.
HEENT: Head is normocephalic, atraumatic. Eyes: Positive red reflex bilaterally. Ears: Left TM is red, bulging and erythematous, fluid behind the membrane, loss of landmark and light reflex. Right TM is pale. Nose: There is some clear rhinorrhea. Mouth: Oral mucosa is moist. No lesions.
NECK: Supple, shotty cervical adenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs.
ABDOMEN: Nontender, nondistended, soft. No hepatosplenomegaly.
SKIN: Warm and dry. Cap refill less than 2 seconds. No rashes or lesions.
NEUROLOGIC: Age-appropriate tone and activity.

ASSESSMENT:
1.  Acute left otitis media.
2.  Rhinorrhea.

PLAN:  We will start her on cefdinir for the otitis media. If symptoms do not improve or worsen in 48 hours, return to clinic. Discussed, with the rhinorrhea, it could be just simple rhinorrhea or mild allergic rhinitis. Either way, we are going to treat it the same with Zyrtec 3 mL at night. Also, recommended a cold air humidifier. If symptoms worsen or do not improve, return to clinic, otherwise follow up p.r.n. We will also do her 12-month shots as she has not had these done. Clinically, she is well and stable and afebrile, so there are no contraindications. All questions were answered. Mother verbalizes understanding and agreement of today’s discussion and advice.

The post Otitis Media Pediatric SOAP Note Example Report appeared first on Medical Transcription Sample Reports.

SUBJECTIVE: This is a (XX)-year-old male seen in followup for possible worsening of obstructive sleep apnea. The patient initially presented prior with a chief complaint of chronic rhinosinusitis and nasal congestion along with worsening obstructive sleep apnea. The patient has had a known diagnosis of obstructive sleep apnea since about 16 years ago. He has been on CPAP since that time.

However, over the past year or so, he has noted that the CPAP machine has become less effective for him. He also notes chronic nasal congestion with a sensation of continued nasal drainage. He denies frank facial pain or headaches. Because of his symptoms, he subsequently was sent for a CT scan of the sinuses as well as repeating of the sleep study, since he has not had one for the last 16 years or so. He returns in followup following the CT scan.

In the interim, the patient continues to note continued nasal congestion and drainage. He is on a nasal steroid spray along with Allegra that he takes daily. He has been taking these medications for the last year or so with minimal benefit in nasal symptoms. He also notes continued daytime somnolence and feels that he is requiring a lot more hours of sleep in order to feel rested the following morning.

The CT scan that was obtained demonstrated pansinusitis with an obstructing mucous retention cyst in the left maxillary sinus that is obstructing the ostiomeatal complex on the left side. However, on our review of the CT scan, there seems to be a mild mucosal thickening of the maxillary sinuses bilaterally, left greater than right, with some mucosal thickening of the left ethmoid sinus. We do note the mucous retention cyst that is in the left maxillary sinus that is indeed obstructing the ostiomeatal complex.

Of note, the CT scan also notes a possible pituitary mass that is eroding the sella turcica as well as the bone of the sphenoid sinus. The patient has no previous studies that we can see; however, upon questioning the patient, he states that he has a known diagnosis of a prolactinoma and is followed by an endocrinologist. He states that the last CT scan he has had was about one or two years prior and, according to the patient, showed that the mass was smaller than on previous exam.

OBJECTIVE: On physical examination, the patient is well developed, well nourished, in no acute distress. Extraocular movements are intact. Visual field exam shows no evidence of hemianopsia. He has full visual field acuity bilaterally. Nasal exam demonstrates pink mucosa without any evidence of nasal drainage. The turbinates are moderately sized. On oral exam, the patient with a long uvula and redundant soft tissue. Tonsils are 1+. The neck is soft and supple. There is no palpable lymphadenopathy. The patient has full range of motion of the neck.

ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman who was referred to us with chronic rhinosinusitis as well as worsening of his obstructive sleep apnea. He was also noted to have a pituitary mass on CT scan that is eroding the bone of the sella turcica.

In regards to the rhinosinusitis, we recommend continuing the nasal steroid sprays and the Allegra. We will readdress this rhinosinusitis once the patient comes back for further evaluation. The plan is to make sure that the patient undergoes the repeat sleep study and to return to our clinic after the sleep study is performed.

In regards to the pituitary mass that the patient states is a known prolactinoma, we recommend that the patient get a copy of his CT scan obtained here and bring it to his own endocrinologist to ensure that the mass has not changed in size or depth of invasion. The patient fully understands the importance of doing this and agrees to that plan.

The post Rhinosinusitis SOAP Note Sample Report appeared first on Medical Transcription Sample Reports.

SUBJECTIVE: The patient was seen and examined at bedside. The patient’s son was in the room as well. The patient denies any nausea or vomiting at the current time. Continues on Neo-Synephrine, which is being weaned down. Blood pressure is stable.

OBJECTIVE:
VITAL SIGNS: Heart rate 106, blood pressure 96/56, and respiratory rate 20.
GENERAL: NAD, conversant.
HEENT: Anicteric sclerae. No lid lag or proptosis. PERRLA. Tonsils not visible.
NECK: Nontender. No masses.
HEART: PMI nondisplaced. S1 and S2 heard. No bipedal edema.
LUNGS: Clear to auscultation. Normal respiratory effort.
ABDOMEN: Soft, BS normal, no HSM.
NEUROLOGICAL: The patient is alert, awake, oriented to self, recognized the examiner and her son. The patient knows she is in the hospital.

LABORATORY DATA: Studies done included CBC with white blood cell count of 14.4, hemoglobin 12.4, hematocrit 36.8, and platelet count 276. BMP with blood glucose of 128, BUN 7, creatinine 0.78, sodium 140, potassium 3.2, calcium 8.2, CO2 of 25, and anion gap 14. Lactic acid done yesterday was elevated at 3.5. Abdominal x-ray is showing no evidence of bowel obstruction. Urine culture is showing no growth.

ASSESSMENT AND PLAN:
1.  Right internal carotid artery stenosis: Status post internal carotid artery stent. On aspirin and Plavix.
2.  Hypertension: The patient has been running low blood pressure since her stent placement. On IV fluids and Neo-Synephrine, also on midodrine. Neo-Synephrine is being weaned down.
3.  Multivessel coronary artery disease: The patient will need outpatient evaluation for coronary artery bypass graft. She will need to be on aspirin and Plavix for now given her stent.
4.  Nausea and vomiting: Improved. Exact etiology unclear. She does not seem to be in acute pain. Abdominal x-ray does not show any acute abnormality.
5.  Metabolic acidosis: Likely related to her nausea and vomiting, noted yesterday on her BMP, resolved.
6.  Elevated lactic acid level: Lactic acid level yesterday elevated. This is likely secondary to hypovolemia/hypoperfusion. We will recheck.

The post Right Internal Carotid Artery Stenosis Sample Report appeared first on Medical Transcription Sample Reports.

SUBJECTIVE:  The patient is a (XX)-year-old Hispanic male who presents for concerns regarding left-sided gynecomastia. The patient is accompanied by his father and mother who are supportive. He complains about left-sided gynecomastia that has increased in size over the past one to two years. He initially saw Dr. John Doe for an endocrine workup. His blood work was all negative, including analysis of testosterone levels. He was then referred to Dr. Jane Doe, a breast surgeon. Dr. Jane Doe has referred him to us for evaluation.

OBJECTIVE:  On examination of the chest, the patient has left-sided gynecomastia. There is mild areolar hypertrophy with palpable excess breast tissue. There is minimal adiposity that the patient presents with. The breast tissue is firm to palpation, and there is some mild ptosis and excess skin of the left chest as well. There are otherwise no masses to palpation of his chest.

ASSESSMENT AND PLAN:  Left-sided reduction gynecomastia. We informed the patient and his family that he has two main issues. There is excess breast tissue causing excess fullness, and there is some possible excess skin. We informed them that the excess breast tissue can be excised directly utilizing a periareolar incision and resultant scar.

Another option would be to make a smaller scar and use the arthroscopic shaver. Due to the fact that he does not have a hairy chest and he is a young male, we are recommending the arthroscopic shaver to start out with at least in order to remove any extra breast tissue. He would then need to wear an abdominal binder to compress the area for several months afterwards to allow the skin to retract as good as possible.

We informed the patient and his family that the arthroscopic shaver may not be quite as aggressive as direct excision, but we do believe may have a slightly lower risk of complications and have a much less visible and obvious scar. We informed them that if insufficient tissue is removed using the arthroscopic shaver, we could always excise it directly as well. They expressed understanding of this.

We also informed him and his family that the tissue that is removed by arthroscopic shaver is not looked at microscopically by the pathologist, and therefore, if there is an occult breast cancer, this may not be detected. They expressed an understanding of this as well. Therefore, we are recommending the arthroscopic shaver to be used first, application of an abdominal binder to compress the area for several months afterwards. If there is some skin excess, we could consider excision of skin approximately six months postoperatively. If there is still some residual breast tissue, then we could consider removal of the breast tissue in that manner as well. They expressed understanding of possible complications, including unevenness, saucer deformity, hematoma, bleeding, and less than optimal tissue excision. They also expressed understanding of the potential for loose skin postoperatively.

The post Gynecomastia Plastic Surgery SOAP Note Sample Report appeared first on Medical Transcription Sample Reports.

SUBJECTIVE:  The patient presents today complaining of chest tightness when she is running. She states for the past two to three weeks when she has been running, she runs for about a mile, and shortly after that, she starts getting some tightness in her chest and she is breathing really fast, almost like she is hyperventilating, and she has to stop and it takes two to three minutes for her to feel normal again. She does not have excessive sweating, and for the first mile, she has no symptoms whatsoever.

In addition to the chest tightness, she also feels that her arms are feeling weak, squeezed when she is running. She had much more mild symptoms when she was running inside the gym. Her sister has a history of reactive airway disease. There is no family history of premature coronary artery disease or sudden death.

OBJECTIVE:  Blood pressure 108/62. In general, this is a well-appearing, thin, young lady in no acute distress. Lungs are clear throughout. Heart has regular rate and rhythm. No murmurs. Abdomen has normoactive bowel sounds. No bruits. On examination of the extremities, PT pulses 2+ bilaterally. No edema in either lower extremity.

DIAGNOSTIC DATA:  EKG reveals sinus rhythm at a rate of 72 beats per minute. No acute ST or Q wave changes noted, within normal limits.

Office spirometry revealed mild obstruction in the small airways with the FEF25-75% 56% predicted. Peak flow was 76% predicted. Remainder of the lung volumes were within normal limits.

ASSESSMENT:  Probable exercise-induced asthma.

PLAN:
1.  Albuterol metered dose inhaler 2 puffs 15 minutes before exercise.
2.  The patient and/or her mom will call in the next two to three days on her progress, and if she is not having any improvement with the albuterol inhaler, then she will be referred to Cardiology for full evaluation.

The post Chest Tightness SOAP Note Transcription Sample Report appeared first on Medical Transcription Sample Reports.

MEDICATIONS:  Tiazac, Ecotrin, Univasc, Zetia, Celebrex, Lescol, Glucophage, and Bextra.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  She is not presently smoking or drinking.

OBJECTIVE:
GENERAL: Awake, alert, in no acute distress.
VITAL SIGNS: T: 97.8. P: 82. R: 18. WT: 154. BP: 132/62.
HEENT: PERRLA. There is no jaundice, cyanosis or pallor. Funduscopic evaluation shows a flat optic disk with normal retinas. She does have bilateral implanted lenses.
NECK: Supple. Negative JVD. Negative carotid bruit. No thyroid enlargement.
LUNGS: Clear to auscultation bilaterally.
HEART: RRR. No murmurs.
ABDOMEN: Soft, positive bowel sounds. No hepatosplenomegaly.
EXTREMITIES: Negative clubbing, cyanosis or edema. Good range of motion.
LYMPHATICS: Negative lymphadenopathy in the cervical, axillary or inguinal areas.
SPINE: Normal curvature and normal range of motion.
SKIN: Some scattered seborrheic keratoses, but there are no signs of skin cancer or melanomas.
NEUROLOGIC: Nonfocal.

LABORATORY DATA:  We reviewed her laboratory reports. CMP was fine with the only exception of glucose of 128. Lipid panel meets ATP III criteria. CBC with platelets is within normal limits. HbA1c was 6.4, which denotes very good control.

ASSESSMENT AND PLAN:
1.  Type 2 diabetes mellitus. She is having a very good response to Glucophage, medication that she is to continue. It has been more than a year since her last diabetic evaluation. The patient wants to be sent to see Dr. John Doe. We will repeat HbA1c and also urine microalbumin before her next visit.
2.  Dyslipidemia, cholesterol very well controlled. She is on the combination of Lescol and Zetia, medications that she is to continue.
3.  Hypertension, very well controlled. She is using an ACE inhibitor in the form of Univasc, and she is also taking Tiazac. We will continue on these medications.
4.  History of right lower quadrant hernia. This is an incisional hernia from her previous appendectomy. This is not giving her any problem. We will just observe.
5.  Health maintenance. She had a mammogram, which was category 2. She had a colonoscopy four years ago that was within normal limits, done with Dr. Jane Doe, and she refuses to have screening Pap smears.
6.  Follow up in March.

The post Followup Evaluation Type 2 Diabetes SOAP Note Sample appeared first on Medical Transcription Sample Reports.

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.

The post Rheumatology SOAP Note Transcription Sample Report appeared first on Medical Transcription Sample Reports.

OBJECTIVE:  On his examination, his blood pressure was 162/74, pulse was 72, respirations 22, and temperature 99.2 degrees. His lungs were clear to auscultation. Cardiac examination showed regular rate and rhythm. Normal S1 and S2. Abdomen was soft and nontender. Good bowel sounds noted. His extremity examination was unremarkable. He was very emotionally labile as indicated. He had fair movement in the right upper extremity with elbow flexion in a synergy pattern. He did have weakness, however, in the hand and intrinsic muscles. In the right lower extremity, he is demonstrating good strength. At the time when I saw him, he was not experiencing any hiccup.

LABORATORY DATA:  On review of his laboratory data, everything appeared stable; although, this BUN and creatinine were still slightly elevated at 34 and 1.4. We will need to continue to monitor this.

ASSESSMENT AND PLAN:
1.  Blood pressure: His blood pressures have been stable with Cardizem, lisinopril, and Norvasc. We will repeat a BMP on Thursday, and if that continues to trend upward, we will arrange for internal medicine consultation as well.
2.  Emotional lability: This is certainly related to Decadron. We explained to his wife that short-term use of a serotonergic agent maybe beneficial; however, at this point, he was reluctant to be on any other medication. We did meet with him with the rehabilitation psychologist and the plan would be to utilize psychology supportive counseling for now and monitor whether something such as Zoloft would be beneficial.
3.  Deep venous thrombosis prophylaxis: The patient’s Doppler did show a superficial thrombus in the saphenous, otherwise was stable. Will progress with activities as ad lib. Continue on the Fragmin.
4.  Diabetes: His blood sugars were very elevated last evening; however, it was only 134 for fasting and 234 at 10:30. We will not adjust his insulin right now, but continue to monitor at this point whether further adjustments are necessary.
5.  Bladder: It appears that he is voiding; however, did not discern any postvoid residuals. We wrote once again for nursing to obtain these.
6.  Sleep: His sleep seems somewhat restless, and therefore, we scheduled trazodone with a repeat ordered as well.
7.  Elevated alkaline phosphatase: The rest of his liver enzymes were normal, but we will continue to monitor this.
8.  Potential coronary artery disease with the diabetes and hypertension: We will check to see if we can have a copy of the EKG faxed from the previous facility.

More SOAP Note Samples

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SUBJECTIVE:  The patient is much more calmer. He reports no specific complaints. He was observed ambulating with physical therapy and did fairly well. He did have his foot Ace wrapped. He was noted to have a fairly pronounced genu recurvatum. He also held his leg externally rotated.

OBJECTIVE:  His blood pressure was 124/64, pulse 86, respirations 18, and temperature 98.6 degrees. Lungs were clear to auscultation. Cardiac examination with regular rate and rhythm. Normal S1 and S2. Abdomen was soft and nontender with good bowel sounds. Extremity examination with no edema noted. He had atrophy in his intrinsics on the right hand. On neurologic examination, he was demonstrating good elbow flexion but still very little finger movement or grip on the right hand. He was beginning to demonstrate volitional ankle dorsiflexion and plantarflexion on the right and appeared to be doing much better with that. Also, he had less apraxia of speech.

ASSESSMENT AND PLAN:
1.  Cerebrovascular accident: We discussed the case in team conference and actually the patient has made significant progress since last week. He did not seem to have the pronounced fatigue that he had had initially and appears to be acclimating to the radiation treatment. He has progressed in all therapy areas and at this point may be able to get to the point where he could be discharged home with his wife. We will discuss this further with her.
2.  Diabetes: His blood sugars have been in fairly good control on the current regimen. He is on low dose of insulin. We will consider taking him off the insulin and using oral hypoglycemic medications. We will check with him further about this.
3.  Hypertension, stable on current regimen.
4.  Gait abnormality: We did write for a custom-molded AFO to see if this will work for him. We also discussed with Dr. John Doe about Botox injections for the posterior tibialis muscle depending on how he does with therapy.
5.  Azotemia: His BUN and creatinine are much improved. Now, his BUN is only slightly elevated and his creatinine has decreased to a normal range.
6.  Deep venous thrombosis prophylaxis: It was reported in the therapy that he is walking greater than 120 feet x2, and therefore, we will be able to discontinue his subcutaneous heparin.

The post Progress Note SOAP Note Transcription Sample Report appeared first on Medical Transcription Sample Reports.

CURRENT MEDICATIONS:  Duragesic patch 25 mcg; Imdur 60 mg, one in the a.m. and half in the p.m.; Zocor 40 mg; Toprol-XL 50 mg; Altace 10 mg; Zyrtec 10 mg; nitroglycerin p.r.n.; quinine p.r.n.; Prevacid 30 mg; Niaspan 500 mg at bedtime; Ultracet b.i.d. p.r.n.; Actonel 35 every week; and Norvasc 5 mg.

ALLERGIES:  No known drug allergies.

OBJECTIVE:
VITAL SIGNS:  T: 98.4. P: 86. R: 26. WT: 144. BP: 126/62.
HEENT:  Normocephalic, atraumatic. PERRLA. No icterus or conjunctival inflammation. TMs clear bilaterally. 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.

ASSESSMENT AND PLAN:  We will do CBC, Chem, sedimentation rate, and a D-dimer today. The patient will be set up for the morning to get a CT of the chest with PE protocol with half the usual dose given his age and mild cardiomyopathy. In the meantime, we will treat the pain with a Lidoderm patch. We have instructed his wife on how to use it and also get some T-spine films. We have discussed the differential diagnoses, includes pleurisy, pulmonary embolic phenomenon, recurrence of shingles or a T-spine compression fracture with radiating pain to the right hemithorax. Since there is not so much abdominal pain, intra-abdominal process is less likely. We will see the patient again in one week. We have instructed the wife to call us immediately if he does have appearance of the classic rash of shingles.

DIAGNOSES:
1. Right pleuritic pain.
2. Ischemic cardiomyopathy.
3. History of shingles.

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SUBJECTIVE:  The patient has been coughing, short of breath since Thursday. She said she got it flared up by someone’s perfume. She was better on Friday. Today, she is worse again, took some Depo-Medrol 160 mg today. She is coughing. She has no productive phlegm. She has tightness in her chest, and she took some Vantin 200 mg twice a day for 4 days, doxycycline 200 mg twice a day. She was not put on any oral steroids. Her peak expiratory flow rates at home have been greater than 250.

OBJECTIVE:  On exam today, the patient is coughing, dyspneic. Blood pressure is pending. Respiratory rate 24. Saturations on room air 98%. HEENT: She has no lesions or thrush. Neck is supple without adenopathy. Lungs: She has mildly decreased breath sounds with an expiratory wheeze. She is moving fairly good air. She has increased respiratory effort. Abdomen: Benign. Extremities: No edema.

ASSESSMENT:  She has status asthmaticus with cough. It was secondary to her underlying asthma, allergic symptoms, and a prolonged QT.

PLAN:  The patient needs Vantin, which she will continue for 6 more days. She needs to go home. Her peak expiratory flow in the office was 400 pre-bronchodilator. She is taking a treatment right now. We gave her prednisone burst and taper. We will see her back next week. If her symptoms worsen or she does not improve, she needs to go to the emergency room. The patient understands that.

More SOAP Note Examples

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SUBJECTIVE:  This pleasant (XX)-year-old gentleman unfortunately continues to experience dyspnea with low levels of activity. He continues to participate in pulmonary rehab and appears to be very compliant with his medications and involved in his care. Reviewing his prior CT scan of the thorax, unfortunately, there was considerable pulmonary disease that we may not be able to do anything about.

OBJECTIVE:  Weight is stable at 204 pounds. Saturations on room air 95% at rest. Pulse is 75 per minute. Respiratory rate of 24 per minute. Blood pressure is 124/72. Head and Neck: There is no evidence of supraclavicular adenopathy. Heart: Regular. Lungs: Diminished breath sounds but no significant wheeze. Extremities: Demonstrate no cyanosis, clubbing, or edema.

ASSESSMENT:  Advanced underlying chronic obstructive pulmonary disease and emphysema with chronic dyspnea with exertion.

PLAN:  At this point in time, we would like to start Spiriva one capsule daily. He is not to use his Combivent while he is on this. We have provided him with a Proventil HFA. He will receive a prescription for Spiriva and Proventil. We would like to see him once again in 4 weeks to see how he is doing. He should continue with his Advair 100/50 mcg. We will see him once again and comment further with regards to changes in his regimen after next visit.

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OBJECTIVE:  Vital Signs: Temperature 98.6 degrees, pulse 104, respirations 20, and blood pressure 200/96. Dorsalis pedis and posterior tibial pulses are nonpalpable bilaterally. Using Doppler ultrasound, the posterior tibial pulses are audible. However, the dorsalis pedis is not audible in the bilateral lower extremities. There is erythema noted to the right forefoot and is most pronounced in the digits 1 and 4. Proximal streaking is noted extending from the dorsal surface near the fourth interspace extending proximally over the foot and also is located at the lateral aspect of the fourth digit on the right foot. The ulcer measures approximately 1 cm x 1 cm in size; has a dark, dry fibrotic base with surrounding macerated borders. There is no drainage, no malodor appreciated. Skin is cool to the touch. Sensation is diminished in the bilateral lower extremities. Muscle strength is within normal limits.

LABORATORY DATA:  WBC 16.4, hemoglobin 14.2, hematocrit 41.6, and platelets 342,000. Sodium 136, potassium 4.2, chloride 102, CO2 of 24, BUN 18, creatinine 0.9, and glucose 280. Wound culture of the right fourth digital ulcer, 3+ gram-positive cocci, 1+ gram-positive rods. Blood cultures x2 pending at this time. Urine culture, 3+ bacteria.

RADIOLOGICAL DATA:  Three views of the right foot, no soft tissue emphysema, no fractures or dislocation. No evidence of osteomyelitis.

ASSESSMENT:
1.  Right foot ulcer with cellulitis/lymphangitis.
2.  Diabetes mellitus.
3.  Hypertension.
4.  Urinary tract infection.

PLAN:  At this time, continue IV antibiotics until further recommendations are made by Infectious Disease. We will order serial Dopplers, bilateral lower extremities. The patient has been advised to keep the right leg elevated when at rest and to minimize weightbearing as much as possible on the right leg. Further recommendations to follow.

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