SUBJECTIVE: This (XX)-year-old woman returns to the wound care center for followup of left plantar foot wound. The patient comes in without any dressing on her foot for approximately the fourth time in the last few weeks. The patient states that she was too tired to put her dressing on. She recently took a medical leave from work for the next three months to try and stay off her feet. She has been taking her antibiotics and denies any constitutional symptoms at this time.
OBJECTIVE: The patient has a large wound on the plantar aspect of her left forefoot area. There is a significant amount of periwound callus with maceration. She also has a malodor coming from the foot wound. The wound bed is fibrotic with some bleeding with debridement. The foot appears to be much more swollen than last visit. There is no streaking or purulent drainage. No bone visible in the wound at this time. The patient is status post left first ray amputation and right BKA. Left plantar foot wound is cultured today. The patient is also being sent for hemoglobin A1c to assess her diabetes.
1. Left plantar foot wound.
2. Chronic osteomyelitis.
3. Diabetes and peripheral neuropathy.
4. Status post right below-knee amputation.
1. The wound on left foot is sharply debrided.
2. The patient is to continue doing daily dressing changes with silver alginate.
3. Discussed with patient about not wearing a dressing. Tried to explain to her that not having a dressing is a health risk to other patients as well as to her. The patient does have a history of MRSA and it is not acceptable for her to be coming to the clinic without a dressing for her foot wound. The patient understands that if she continues to come into the clinic without a dressing on her infected foot, she may be barred from returning to the wound care center. The patient understands and will try to keep her wound covered.
4. Discussed with patient about using a special boot to help offload the forefoot when she does walk.
5. We will send a prescription to have a specially molded CROW boot made to help offload the forefoot and help allow for wound healing.
6. Once we receive culture results, we will call the patient if any antibiotics need to be added or changed.
7. The patient is to follow up in one week.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #2
SUBJECTIVE: The patient was seen on an emergency basis today when he called complaining of left upper quadrant pain. It has been building up for about three months, and his most prominent symptom is increased belching. He also has increased satiety, heartburn, and intermittent left upper quadrant pain. No dysphagia, melena, change in bowel habits, or vomiting. No fever, chills, or rigors. He has not been testing his sugars, and there has been no dyspnea or chest discomfort with exertion. No orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No myalgias. Osteoarthritic symptoms are stable.
OBJECTIVE: He is alert and oriented and in no distress at rest. Blood pressure 122/74, pulse 82 and regular, respiratory rate 18 and unlabored, weight 290 pounds, oxygen saturation is 98%. Temperature 98.4 orally. HEENT: Reveals no sinus tenderness and posterior pharynx is clear. Neck is supple without thyromegaly or adenopathy. Lungs are clear to auscultation and percussion. Heart: Regular rhythm. S1, S2. Abdomen: Normal bowel sounds, soft with possible left upper quadrant tenderness, but he says no. He belches every time on palpation of the left upper quadrant. No mass or hepatosplenomegaly. Extremities: Without edema.
1. Abdominal pain, most consistent with acid peptic symptoms, no red flags.
3. Non-insulin-dependent diabetes mellitus.
1. We discussed what Dexilant is, how it works, and potential side effects.
2. Dexilant 60 mg p.o. daily.
3. Call if any new symptoms develop or current symptoms worsen.
4. Return in two weeks.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #3
PROBLEM: Left middle trigger digit, right middle and ring trigger digits, and right carpal tunnel.
SUBJECTIVE: The patient presents today to discuss electrical studies. Electrical studies done today showed a normal study within the upper limits for right carpal tunnel syndrome. Dr. John Doe recommended repeating electrical studies in 6-12 months if symptoms persist. The patient states she has been wearing a splint, and she has only had numbness 3 times in 4 weeks. She does continue to have locking of her digits. Her greatest pain is in the ring finger.
OBJECTIVE: She is neurovascularly intact to sensation and motor. She has pain at the A1 pulley of the right ring finger with locking noted. Capillary refill is brisk. Normal skin turgor and texture.
ASSESSMENT AND PLAN: Ring trigger digit. Recommended cortisone injection. After appropriate discussion, she wished to proceed. The patient was given 1 mL of Depo-Medrol 0.5 mL along with 0.5 mL of 2% lidocaine to the right ring finger flexor tendon sheath. She tolerated the procedure well. We will see her back in 4 weeks’ time with a question of injection to the next most affected digit
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #4
SUBJECTIVE: The patient is a (XX)-year-old female, who comes complaining of bilateral ear discomfort, right greater than left. She has been having it intermittently for about a week or two and she said it is worse at night, better in the daytime. She reports no discharge from ears. She does have a history, three years ago, of having a right tympanic membrane perforation that healed spontaneously. She has had no buzzing, no loss of hearing, no blocked sensation of the ear. She had been swimming recently, and she was concerned about an infection that she may have picked up while swimming. No other recent travel or sick contacts. No fevers, chills, nausea, vomiting, or sweats. No headaches or visual disturbances. No sinus pain or pressure. No temporomandibular joint symptoms. No teeth grinding symptoms. She has some mild tender neck glands, particularly on the right. No sore throat. No postnasal drip and no cough. No shortness of breath. No wheezing. She is otherwise feeling well.
OBJECTIVE: On examination, the patient is a well-developed, well-nourished female. She appears in no acute distress. Her blood pressure is 132/74 with a pulse of 64. Temperature is 98.6. Her pupils are equal, round, and reactive to light. Extraocular muscles are intact. There is no tenderness to opening and closing of the jaw at the temporomandibular joint. There is minimal discomfort to tugging on the pinna on either side. The tragus is nontender on either side. Canals are clear. Tympanic membranes are with good light reflex. There is no retraction. There is no bulging of the drum. There is no fluid seen behind the tympanic membranes. There is no debris or discharge noted in canals. There is no wax. The neck is supple. No cervical lymphadenopathy. There is no frontal maxillary sinus tenderness noted. She has good range of motion of the head about the neck and flexion-extension, side-to-side rotation. Lungs are clear to auscultation, and heart exam shows normal S1, S2, no murmurs appreciated. Peripheral pulses are intact. No other oral lesions are noted, minimal injection of posterior pharynx only.
ASSESSMENT AND PLAN: Overall impression is bilateral otalgia with a normal exam. Ear complaint was not found, and there was no sign of any infection. We have reassured her that at this point in time things look good. If things get worse, she will have to call up. Right now, the exam is quite normal and no antibiotic is needed at this time. Follow up as needed.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #5
SUBJECTIVE: The patient continues to complain of right gluteal pain. The father also expressed concern that the pain has not gotten better over the last five months. He is hoping that since his son is an inpatient, that the pain problems can be taken care of as an inpatient. He was reminded that the rehabilitation stay is for rehabilitation with hopes that pain relief can be addressed as well. The patient denies any chest pain or shortness of breath. He states the Capzasin did not help with his gluteal pain. He is wondering if there is something else that can be tried.
OBJECTIVE: Temperature 98.2 degrees, pulse 78, respirations 18, and blood pressure 110/70. Intermittent catheterization volumes are in the 200 to 300 mL range, and he has had some incontinence on occasion. He has also had some soft-formed bowel movements on occasion as well. Head and neck examination was unremarkable. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. An intrathecal baclofen pump was noted in the right lower quadrant of the abdomen. There was no lower extremity edema. The patient did not wear any support hose. Along the medial aspect of the thigh, was a 3.5 x 1.5 area of granulation tissue at the former area of a burn. No induration was noted. Slight serous drainage was noted.
ASSESSMENT AND PLAN:
1. Right gluteal pain: Continues. We will discontinue the Capzasin since this is not helping. We will begin a trial using 5% Lidoderm patches to the gluteal area with the patch placed 12 hours on and 12 hours off. We will also work to try to get the patient to see Dr. Doe to address the location of the catheter as this might be contributing to the pain he is experiencing. Apparently, he has had this pain since the new catheter was placed.
2. Right medial thigh burn: Good granulation tissue formation. Continue the Adaptic dressing as written. The other burn area has now scabbed over with no evidence of erythema, increased warmth or swelling.
3. Neurogenic bladder management: The patient continues to have fair bladder volumes and episodes of incontinence. We will send a urine specimen for urinalysis, culture and sensitivity. We will make sure there is no urinary tract infection before further workup is considered. We will increase the Ditropan XL to 10 mg daily to see if this would not help increase bladder volume and decrease episodes of incontinence.
4. Pain: Continues in the perirectal area. Continue present management in addition to having the patient seen and evaluated by Dr. Doe.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #6
SUBJECTIVE: The patient is a (XX)-year-old man who I first saw on MM/DD/YYYY when he was looking for a second opinion regarding his left internal carotid artery occlusion versus near total occlusion. His complaints included, about (XX) years ago, developing diplopia which occurs when looking to the left or the right, which has not changed since then. He was found to have a possible left internal carotid artery blockage and was seen by Dr. Doe about six years ago, who started him on Plavix. He was also being followed for what is reported as a distended left cavernous sinus. Since I last saw him, he has not had any new neurologic symptoms. He did have an MRI and MRA performed. I reviewed these films with him showing him the small hyperintensities, particularly in the left centrum semiovale region. This was unchanged compared to his previous MRI. He did have gadolinium injected, and with the gadolinium injection, the aortic arch was viewed as well as all of his cervical and intracranial vessels. He did have a normal appearing left common carotid artery, but the left internal carotid was occluded at the origin. His right carotid artery and bilateral vertebral arteries appeared normal in caliber. He has normal flow through the middle cerebral artery and anterior cerebral artery bilaterally. He does have some mild to moderate atrophy on MRI of his brain and there are no changes in terms of his left cavernous sinus. In particular, there is no lesion to explain any cranial nerve dysfunction that was causing him to have diplopia. He is on Plavix 75 mg daily. He takes some nasal spray and he occasionally takes antianxiety medications as well as multivitamin once a day.
OBJECTIVE: On examination, his weight is 201.7 pounds which is unchanged compared to his last visit. His temperature is 98.5. His blood pressure is 126/80. His heart rate is 72. His respirations 22. His neck is supple without bruits. Lungs are clear to auscultation bilaterally. Heart is regular rate without murmurs. Abdomen is soft with normoactive bowel sounds, nontender. He has no edema on extremity examination. On neurologic examination, he is alert and fully oriented with normal speech and language. His pupils were equal, round, and reactive to light at 4 mm and extraocular movements were nearly full, but with bilateral lateral gaze. He does have nystagmus. When he looks fully to the left and fully over to the right, he complains of vertical diplopia which is worse on the right gaze. When he looks straight ahead, he does not note any diplopia. He has no ptosis. Motor examination is 5/5 strength throughout and had no pronator drift; although, I had noted a slight right pronator drift on his last visit. Sensation was normal to light touch.
ASSESSMENT AND PLAN: My impression is that the patient is a (XX)-year-old man who has a completely occluded left internal carotid artery at the origin. With that, he has developed collateral flow and he does have some tiny hyperintensities, particularly in the left hemisphere, that may have been related to narrowing carotid artery in the past. He did have some question of slight trickle of flow on a conventional angiogram performed in the past, but there is clearly no flow on this MR angiogram with gadolinium. Given that the vessel appears completely occluded, I told him that the best treatment is for him to keep well hydrated and to help with his collateral flow as well as to continue on his antiplatelet agent, which is Plavix. I explained that interventional maneuvers such as stenting or carotid endarterectomy were not possible with an occluded vessel. We also discussed treating his cholesterol for which he is on Pravachol and he will try to obtain the results of this most recent fasting lipid profile, so that I can determine that he is on an appropriate dose of Pravachol. He will obtain the names of his medications and dosages and call my office with those. We also discussed his difficulties with insomnia and I recommended again that he see his urologist, as he does have some nocturia. With regard to the questionable left cavernous sinus findings on MRI in the past, there have been no changes with this MRI, so I will not recommend any further imaging studies as I am not seeing any abnormalities there. As far as his diplopia, he states that prisms did not work for him. I told him that he could follow up with me as needed in future and emphasized the need to treat his risk factors for stroke including his hypercholesterolemia.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #7
SUBJECTIVE: This is a followup visit regarding arthralgia. The patient was sent here for a question of Ehlers-Danlos. The previous note outlines why we do not think the patient has Ehlers-Danlos, based on her exam, she has no joint hypermobility or abnormal skin texture. The patient has some chronic back pain and knee pain with degenerative changes in her low back and likely patellofemoral OA in her knees. She carries a diagnosis of colitis and consequently does not take oral NSAIDs on a regular basis. We gave her some Voltaren gel last visit, which was very helpful for her knee pain. We have given her three additional samples at today’s visit.
PAST MEDICAL HISTORY: Notable for chronic obstructive pulmonary disease, intussusception of bowel, spinal stenosis, smoking, depression, GERD, osteopenia, irritable bowel, hysterectomy, cholecystectomy, colectomy, carcinoid tumor, and arthralgia. She has not done the physical therapy that we prescribed for her when we saw her at last visit for her knees.
MEDICATIONS: Hydrocodone, oxycodone, Spiriva, Advair, paroxetine, alprazolam, omeprazole, prochlorperazine, and fluticasone.
OBJECTIVE: Blood pressure 104/68, heart rate 72, 168 pounds, temperature 99.2. Full range of motion of neck, shoulders, elbows, wrists, knees, and ankles. There is no swelling or synovitis in these joints, and her joints are hypermobile. Lungs are clear. Heart has regular rate and rhythm, S1, S2. Abdomen is soft and nontender. No clubbing, cyanosis, or edema. No positive straight leg at today’s visit.
The patient says since we last saw her, she has been having worse problems with dyspnea on exertion. She is supposed to be having a stress test in followup, and she also had an episode of paroxysmal supraventricular tachycardia for which she was treated with adenosine and she stayed in the hospital overnight after the arrhythmia.
ASSESSMENT AND PLAN: We do not think the patient has rheumatoid arthritis or Ehlers-Danlos. She has spinal stenosis and some mild degenerative arthritis. We have the Voltaren gel that she can use at her knees, and we encouraged her to physical therapy for her knees that we prescribed at the last visit. She has seen a pain clinic local to her for injections in her back and for spinal stenosis. She can follow up with them. She has other active medical issues such as her diarrhea issues for which she is being referred to GI and her breathing issues for which she can follow up with Dr. John Doe, her pulmonologist, and the stress test she is going to be getting as well. I will see the patient back in six months.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #8
SUBJECTIVE: This (XX)-month-old female was brought in by her father for drainage in both eyes for two days. Daughter had drainage from the eye. Minimal cough, almost none. Runny nose and congestion, mild. There has been no vomiting or diarrhea. No ear pulling. There is no sore throat that father is aware. The child has been acting normally. Eating and drinking normally. No skin rash that the father noticed. Dr. Doe treated an ear infection two weeks ago.
IMMUNIZATIONS: Up to date.
SOCIAL HISTORY: No smoking in the household. Does attend daycare, but does have a private baby sitter.
OBJECTIVE: The patient is alert and appropriate for age, in no acute distress. Cries on exam. Easily consoled. Flat anterior fontanelle. Conjunctivae are injected with bilateral exudates, excoriated from the drainage on the left eyelid. Both TMs were dull and red. Loss of landmarks in the left TM and is bulging. Rhinorrhea is present with purulent nasal drainage. Pharynx is negative. Neck is supple. No lymphadenopathy. Lungs are clear to auscultation. Abdominal exam is unremarkable. No rash. No petechiae. Child has normal color. Oximetry is 97% on room air. Vital signs were stable.
1. Bilateral otitis media.
2. Bilateral conjunctivitis – infectious.
PLAN: Polytrim eye drops, 2 drops 4 times a day for 7 to 10 days. Gentle cleanse to reduce the excoriation and mattering. Zithromax 100 mg/5 mL, use as directed. Recheck the ears in 10 days with Dr. Doe, sooner if worse.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #9
SUBJECTIVE: The patient is a (XX)-year-old male who has right distal radius fracture, nondisplaced. The patient recently had a seizure. The postoperative anterior-posterior splint fell off. He has been wearing a removable wrist brace. He reports no pain at rest. Feels that overall his pain has improved, but it is still present.
OBJECTIVE: Clinically, his swelling is much improved. Ecchymosis is resolving. He can nearly make a full fist and fully extend his digits. He continues to be mildly tender at the fracture site, but no instability is noted. There is brisk capillary refill distally and his hand is well perfused. The fingertip is nontender. Neurologically, his sensation is improved and there is no evidence of an active carpal tunnel syndrome. Examined his left knee today. He has had some grinding with range of motion. He states that he has injured it. Right knee is asymptomatic. The patient is able to flex to about 110, extend to 0. He has full 5/5 quadriceps strength, 5/5 hamstrings. He has tenderness along the lateral joint line and along the patellar tendon, but there is no instability to varus or valgus. There is no pain with palpation at the tibia. No evidence of fracture clinically.
ASSESSMENT AND PLAN: X-rays of the wrist demonstrate no interval change. This is nondisplaced. The fracture appears stable. Discussed that an x-ray could be taken today. The patient and his wife are not interested in pursuing that today. We have given him a GenuTrain to assist with symptomatic relief. We have also provided him with wrist lacer splint for the right wrist. Discussed restrictions for the right wrist. We will reevaluate in approximately 4 weeks with x-rays of right wrist. If his knee symptoms worsen, I would recommend x-ray. Questions were answered to his satisfaction
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #10
SUBJECTIVE: The patient is a (XX)-year-old male who was seen last with concern about a scaphoid injury. He has been in cast with a thumb spica. He returns today. Cast is off. Has 1/10 pain. Clinically, he has really no tenderness at the snuffbox, no tenderness at the distal pole of the scaphoid.
OBJECTIVE: The patient’s pain is mainly over the dorsal radial aspect of the thumb, mainly at the thumb CMC and to a lesser extent the index CMC. He does have a spur in this area visualized on x-ray. He is minimally tender in this region. No pain with thumb CMC compression. Motor and sensation are otherwise intact with brisk capillary refill.
X-rays taken today demonstrate some mild degenerative changes at the thumb CMC, but no evidence of acute fracture or dislocation. Scaphoid is unremarkable.
ASSESSMENT AND PLAN: Dorsal radial wrist sprain with some pre-existing thumb CMC arthritis. No evidence of scaphoid fracture. We can get him out of the cast today and place him into a thumb spica splint. He will wear this for protection but remove for bathing and exercises. We discussed use of the hand. Questions have been answered to his satisfaction. We will follow up in approximately one month’s time. He will call me in the interim with concerns.
SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #11
SUBJECTIVE: The patient reports some abdominal discomfort. He notes that he has not had a bowel movement in about a week and has been inconsistent taking his bowel medications.
OBJECTIVE: Temperature 97.2 degrees, pulse 88, respirations 20, and blood pressure 124/82. The head and neck examination was unremarkable. Heart and lung examinations were within normal limits. However, there was an intact chest wound site along the right axillary line and two chest tube sites were noted in the anterior axillary line, on the right. The patient wore a Sarmiento brace with a cap. He is also wearing a Jewett brace. The abdomen was slightly protuberant and hyperresonant to percussion. No masses were noted, though the abdomen was somewhat firm. There was no rebound tenderness. Although, the patient had an apparent right hand swelling. Mid palm circumference was 21.2 cm bilaterally. There was no MCP tenderness in either hand. A 3D brace was noted on the right.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to require encouragement to perform rehabilitation tasks. Once focused on a task, the patient appears to be doing fairly well. Continue comprehensive inpatient rehabilitation.
2. Spine stability: Stable with the Jewett brace.
3. Right humerus fracture: The patient now has a new Sarmiento brace with shoulder cap. This is fitting well.
4. Right hand swelling: Noted at first glance, although, examination was unremarkable. There is no evidence of complex regional pain syndrome, type I. We will continue to follow. We will make sure that the Sarmiento brace is not too tight.
5. Neuropathic pain: The patient states that he is under great control of the pain with Neurontin and Elavil. However, he also reports feeling a bit drowsy. He also notes that he has been inconsistent taking the Neurontin. We will therefore decrease the Neurontin to 600 mg t.i.d. The patient was told the importance of taking medications on a regular basis to maintain blood serum levels of the drug. He appreciated this discussion.
7. Pain: Good control. Again, he mentioned some drowsiness. We will consider decreasing the methadone to 5 mg b.i.d. if drowsiness continues. The pain is not interfering with therapies.