SOAP Note Example Medical Report #1
SUBJECTIVE: The patient is here today with increasing symptoms of his asthma over the past week. He has had no fever. His chest is tighter and his Symbicort is not working. He is using his Ventolin inhaler more frequently.
His past medical history includes asthma, gastroesophageal reflux disease and allergies.
OBJECTIVE: Temperature is 98.4. HEENT: Unremarkable. Neck: Supple without adenopathy or thyromegaly. Lungs: Reveal diffuse wheezes bilaterally. Heart: Regular.
ASSESSMENT: Asthmatic bronchitis.
PLAN: The patient is given prednisone 50 mg to 0 mg taper. He is also given albuterol for nebulizer 4 times a day. We will cover him with antibiotic Zithromax 500 mg once a day for 5 days. The patient will follow up p.r.n. no improvement in his symptoms.
SOAP Note Example Medical Report #2
SUBJECTIVE: This (XX)-year-old patient of Dr. Jane Doe has had pain and a small amount of discharge in the right ear for the last 3 days. She teaches swim lessons and is in the pool all day. There has been no sore throat, cough, cold or coryza. She does not use Q-tips.
OBJECTIVE: Well woman in no obvious discomfort. Minimal irritation without erythema in the right ear canal. The left ear canal is normal. Both tympanic membranes are normal. The pharynx is perfectly clear.
ASSESSMENT: Early otitis externa.
PLAN: Cortisporin Otic solution 3 times a day. Return if not improved.
SOAP Note Example Medical Report #3
SUBJECTIVE: This (XX)-year-old patient of Dr. John Doe has chronic venous insufficiency. He occasionally wears support hose. Last night, he noticed that his left lower extremity was getting red. He has an area of skin breakdown, apparently an abrasion on the lateral margin. There has been no fever or chills. He was on cephalexin for 10 days last year for a similar problem.
OBJECTIVE: Thin gentleman in no apparent discomfort. Temperature is 98.6. The left lower extremity is red, minimal tenderness from knee to ankle.
ASSESSMENT: Cellulitis.
PLAN: We advised ceftriaxone 1 gram IV now. We will start cephalexin 500 mg 4 times a day. We have asked him to apply moist heat to lower extremity tomorrow. Return for reevaluation in the walk-in.
SOAP Note Example Medical Report #4
SUBJECTIVE: The patient is complaining of some intermittent dizziness off and on over the past 4 or 5 months. She was evaluated by somebody at work who thought she had benign positional vertigo and treated her with Antivert. It worked well, but when she stopped taking it, some of the symptoms recurred. She describes a dizzy feeling, primarily with putting her head back but not with any other movements. She has recently developed some tinnitus, which she described as a buzzing noise in her ear. Again, it is intermittent. Her hearing has been okay with no changes noted. She has not been unable to drive, and the symptoms have not interfered with her daily routine.
OBJECTIVE: Blood pressure 122/84, pulse 74 and regular, weight 142. Ears: Canals are clear. TMs are somewhat dull with absent light reflex. Throat: Clear. No exudate or erythema. No lateral banding. Neck: Supple. No increased adenopathy. Chest: Clear to P and A. No rales, rhonchi or wheezes.
ASSESSMENT: Benign positional vertigo.
PLAN: We have told her to use the Antivert on a p.r.n. basis. She also has serous otitis media, and we instructed her in pushing fluids and doing Valsalva. This may very well improve her dizziness somewhat. She also has some intermittent edema in her feet and says that her hands and feet are always cold. On exam, she does have a little purplish color to her distal feet and toes and they do feel cool.
SOAP Note Example Medical Report #5
SUBJECTIVE: The patient is here today complaining of having had her period 3 times in the last 4 weeks. She said that they are not specifically heavier, but she has only 1 or 2 days where it is heavy and then the next day it is only a little brownish discharge. She normally has very regular period, and her period will last about 5 days with mild cramping. She denies any unprotected intercourse. She always uses protection. She denies any breast tenderness. She never had missed any either.
OBJECTIVE: In terms of her exam today, her blood pressure was 114/66, which is about the same for her as before. Heart rate was 66. She weighs 136 pounds. Her temperature is 98.4. Her thyroid exam showed that she has normal thyroid. We could not feel for any masses. She does not have any upper extremity tremor either. Her lung examination was clear. Her cardiac examination showed regular heart sounds. She has no S3 or S4. Conjunctival exam is normal. Eye exam is EOMI and PERRLA. Abdominal examination showed a soft abdomen. She has no hepatomegaly. No splenomegaly.
ASSESSMENT AND PLAN: This is a lady who is here today for menorrhagia. She is (XX) years old. Her symptoms might be related to perimenopause. However, we decided to check her CBC but also to check her thyroid. We explained to her that both hyper and hypothyroidism may cause her symptoms; although, she denies any change in her weight, any agitation or any fatigue. We will then follow up on her lab results, and we also discussed today perimenopausal symptoms.
