ER SOAP Note Sample #1
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Rapid heart rate.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department by squad. Apparently, just prior to arrival, he left work, was in his car, when his heart started racing. He states that he did have some chest tightness, 4/10 in intensity. No shortness of breath, nausea or vomiting. The patient states he had an ablation done in the past. He states he forgot to take his digoxin the last few days. He has never had a stress test.
PAST MEDICAL HISTORY:
1. SVT.
2. Hypertension.
MEDICATIONS:
1. Digoxin.
2. Toprol.
ALLERGIES: None.
SOCIAL HISTORY: The patient denies tobacco use. Occasionally, he drinks alcohol.
FAMILY HISTORY: The patient’s father has had a history of hypertension, and the patient’s grandmother has had a history of coronary artery disease.
REVIEW OF SYSTEMS: All systems are reviewed and otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: BP 152/108, temperature 98.4, pulse 190, respirations 18, O2 sat 98% on room air.
GENERAL: The patient is a well-developed male who appears anxious.
HEENT: Moist mucous membranes.
NECK: Supple, no JVD.
HEART: Tachycardic, otherwise regular rhythm, S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, obese.
EXTREMITIES: No clubbing, cyanosis or edema.
LAB RESULTS: Chest x-ray shows no acute findings by my reading. EKG shows a supraventricular tachycardia with a rate of 190. No acute findings on reading. Troponin normal.
WBC 14.8, otherwise normal CBC. Digoxin level 0.5. Chem-7 is normal, except for a glucose of 118.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. An IV was established in his left antecubital region. He was found to be in supraventricular tachycardia. He was given 6 mg of adenosine without conversion. He was given a repeat dose of 12 mg without conversion. He was bolused with Cardizem 20 mg and started on a drip at 15 mg an hour. He was rebolused with 25 mg of Cardizem. His rate began to come down into the 150s range and then he converted into a sinus rhythm. His old charts were reviewed. We did discuss the patient with Dr. John Doe, who is covering for his cardiology group, and the patient was discharged in good condition.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old male with a supraventricular tachycardia. We will discharge him to home. He is to take his medications as directed. He is to follow up with his cardiologist and return if symptoms worsen.
DISPOSITION: Home.
DIAGNOSIS: Acute supraventricular tachycardia, resolved.
ER SOAP Note Sample #2
CHIEF COMPLAINT: Bilateral eye itching.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents to the emergency department complaining of a 3-day history of eye itching and swelling. The patient states this started in her right eye 3 days ago and spread to her left eye yesterday. Today, both eyes have been bothering her. The patient states it is a little sore around her eyes, but her main complaint is that they are itchy. She has had some clear tearing but no purulent discharge. She states her right eye is a little bit more blurry than usual. She has no eye pain. No sneezing. No runny nose. She had similar symptoms to these a year ago. They were somewhat milder, and she did not seek medical attention. She denies any cough. She denies any pain with eye movement. She denies any foreign body sensation and denies any injury.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
ALLERGIES: None.
CURRENT MEDICATIONS: Per medical reconciliation form.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Positive for one pack per day tobacco use, occasional alcohol use. Negative for illicit drug use.
REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbances, neck pain, chest pain, shortness of breath or abdominal pain. All other systems are negative, except as noted in the HPI.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 118/76, pulse 74, respiratory rate 18, temperature 98.4, pulse ox 98% on room air.
GENERAL: The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, react to light. Extraocular movements are intact. Sclerae nonicteric. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. The patient has no pain with palpation over the globe itself. In her periorbital soft tissues, she has redness and swelling present, but it is not cellulitic redness; it is more of an irritated allergic reaction redness. She has no tenderness to palpation around her eyes. She has no purulent drainage. The oropharynx is clear. Pink and moist mucous membranes.
NECK: Supple, no lymphadenopathy, no thyromegaly. Trachea is midline.
LUNGS: Clear to auscultation bilaterally.
NEUROLOGIC: She is intact. Moving all four extremities symmetrically and spontaneously and following commands. Her left eye was tested. Visual acuity was tested and is 20/50. Her right eye visual acuity was 20/50 as well.
SKIN: Warm and dry. No evidence of rash other than is noted around the eyes.
LABORATORY RESULTS/RADIOLOGY: None.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. She remained hemodynamically stable throughout her stay. She received 50 mg of Benadryl and was discharged home.
MEDICAL DECISION MAKING: The patient presents with evidence of urticaria and allergic-related eye swelling. She has no evidence at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis. She has no evidence of ocular pain to suggest that she would have acute angle glaucoma. This would be unusual in both eyes anyway. She has no evidence of ruptured globe. No evidence of acute trauma and no evidence of cellulitis at this time. She is hemodynamically stable for discharge.
IMPRESSION: Urticaria.
PLAN:
1. The patient is to take Benadryl and Claritin as needed.
2. The patient is to follow up with her clinic, both for this and for medication refills that she is going to need in the near future.
3. She is to return for significant worsening of her symptoms, development of eye pain, worsening of her redness or swelling despite therapy or other concerns.
4. The patient verbalized understanding of the discharge instructions.
DISPOSITION: Discharged home in good condition.
ER SOAP Note Sample #3
SUBJECTIVE: The patient is without complaints, except he would like his baclofen pump addressed so that he can focus his attention on improving his functional abilities.
OBJECTIVE: The patient is afebrile with vital signs stable. The patient is 5 feet 8 inches tall and weighs 156 pounds. The head and neck are unremarkable. Pupils are equal, round, and reactive to light. Extraocular movements are intact. The patient is wearing eyeglasses. There is no apparent facial asymmetry. Heart and lung examinations are within normal limits. The abdomen is soft and nontender with active bowel sounds. A baclofen pump was noted in the left lower quadrant of the abdomen. Knee-high Ace wraps/compression stockings were in place.
ASSESSMENT AND PLAN:
1. Rehabilitation: A team conference was held today to review the patient’s functional goals and progress. The patient requires standby assistance with stand pivot transfers. The patient is independent with catheterization using a Coude catheter. Standby assistance/supervision is required for feeding, grooming, for bathing at the transfer tub bench, for upper extremity dressing, for bowel management, and for bed to wheelchair transfers. Minimal assistance is required for lower extremity dressing, bladder management, toilet transfers, and tub transfers. Based on the patient’s functional goals and progress, his tentative discharge date was established. The patient was told of this and was in agreement with the plan. However, he would like to focus on his baclofen pump for a portion of the rehabilitation stay. Continue comprehensive inpatient rehabilitation.
2. Spasticity: Under fair control. The neurologist will be contacted as far as further evaluation of the baclofen pump is concerned. A dye study is yet to be done.
3. Pain: Under fairly good control. Continue present management.
4. Bladder management: As previously mentioned, the patient is independent with intermittent catheterization. Continue present management.
5. Bowel management: Improving. Continue to work on a regulated program.
6. Hypertension: Under fair control. Continue present management.
7. Lower extremity edema: Improving. The lymphedema management team is assisting with his care.
8. Dementia: Workup in progress. The patient continues to be seen by the neurologist.
