SUBJECTIVE: The patient returns in followup today. We performed an L2 laminectomy with lateral recess decompression prior. She reports progressing well overall. She states that her previous back pain has gone. However, she continues to have some pain in the legs with ambulation. She is concerned that it may be of a vascular etiology. A workup is ongoing per her primary physician.
OBJECTIVE: On exam, the incision has healed completely. Hip flexors, knee extensors, ankle dorsi and plantar flexors are grossly full strength. She is able to heel and toe walk. Light touch sensation is well preserved.
ASSESSMENT AND PLAN: Overall, the patient is recovering slowly from her surgery. We gave her a script to start physical therapy at a site of her convenience. A vascular workup is ongoing. We will have her return to see us in followup in two months to check on her progress.
SOAP Note Sample #2
SUBJECTIVE: The patient returns, status post now five months instrumented fusion of the spine done for a congenital hemivertebra. She is doing very well. She is back to work. She moved filing cabinets several weeks ago, had a week or two of pain, but it has abated. She is not using any medicines.
OBJECTIVE: Exam shows the wound to be healed. She can forward flex to touch her toes, side bend 5, extend 5. Strength is excellent. Reflexes at the lower extremities, knees and ankles are benign. No root tension signs.
Radiographs look very good.
ASSESSMENT: Overall, satisfactory course.
PLAN: Treatment plan is to see her back in six months for one final followup.
SOAP Note Sample #3
SUBJECTIVE: The patient is a (XX)-year-old female complaining of a long history of problems with her right knee. She had seen Dr. John Doe a couple of years ago who recommended some exercises. Her pain has persisted. She has some anterior knee pain that is sometimes sharp at times and medial knee pain.
OBJECTIVE: On examination, she has no significant swelling. Good range of motion with some crepitance.
X-rays show fairly significant arthritis, mostly medial joint space. MRI shows question of medial meniscal tear.
ASSESSMENT AND PLAN: We think the patient’s major problem is coming from arthritis. We told her there is a small chance that her sharp pain can be coming from loose articular cartilage, and ultimately, the last resort would be to consider arthroscopic evaluation and debridement. We think the best thing to do right now is to continue nonoperative management. We will give her a couple of knee braces. We will send her to physical therapy. We injected her right knee with 8 units Kenalog and lidocaine under sterile conditions. Hopefully, this will calm down some of the inflammation as well, and we will see her again in a couple of months for repeat examination.
SOAP Note Sample #4
SUBJECTIVE: The patient is here today with a tick bite on his upper right anterior thigh. He removed it last night and notes that the tick was quite tiny. He is complaining of muscle aches and joint pains. He does not note any fever. He notes that the area around the bite is now erythematous with central area purulent material and blistering.
OBJECTIVE: Blood pressure 140/74. Temperature is 98.8. Skin: On the anterior right thigh, there is a vesicular lesion with surrounding erythema, which is indurated and tender.
ASSESSMENT: Tick bite.
PLAN: The patient is given doxycycline 100 mg one b.i.d. for 21 days. He will follow up if his symptoms persist.
SOAP Note Sample #5
SUBJECTIVE: The patient is a (XX)-year-old female who is actually unclear exactly why she is here. Apparently, she thinks it is for her left shoulder. She had fractured her shoulder in YYYY and had hemiarthroplasty done. She has been doing okay, and she really feels like the shoulder does not hurt her a lot. She has limited motion, but she really has no significant pain.
OBJECTIVE: On exam, she is a pleasant, well-developed, well-nourished female in no acute distress. She abducts her left shoulder actively about 60 degrees and forward flexes the same. Passive motion is somewhat better. She really has no significant discomfort; however, x-rays show high-riding proximal humerus. The patient is with prosthesis in place.
ASSESSMENT AND PLAN: The patient is status post hemiarthroplasty with rotator cuff arthropathy. She really is having no significant pain. We have told the main indication and to get more aggressive would be to treat pain and that could involve a reverse arthroplasty, but she actually is not symptomatic enough to think about a big revision operation. We have told her she can continue to use her shoulder as tolerated, and she will let us know if she has any further complaints.
SOAP Note Sample #6
PROBLEM: Left leg redness.
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 re-evaluation in the walk-in.
SOAP Note Sample #7
PROBLEM: Right earache.
SUBJECTIVE: This (XX)-year-old patient has had pain and a small amount of discharge in the right ear for the last three days. She teaches swimming 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 Sample #8
SUBJECTIVE: The patient is seen in followup regarding his right knee injury. He is approximately three months status post right quadriceps tendon repair. He has been wearing hinged knee brace, which has been unlocked. He has been receiving outpatient physical therapy. At the present time, overall, he is doing quite well. He has no pain.
OBJECTIVE: On examination of the right knee, the skin is examined. The skin is intact. Surgical incision is well healed. There is no knee effusion. There is no soft tissue swelling. The foot is warm and well perfused with brisk capillary refill. Motor and sensory functions are intact distally. Passive range of motion is from full extension to 135 degrees of knee flexion. Arc motion is pain-free. The knee is stable to varus/valgus stress testing. There is mild quadriceps muscle atrophy. His gait is examined; it is nonantalgic in nature.
ASSESSMENT AND PLAN: Right quadriceps tendon rupture. The diagnosis was reviewed in detail with the patient. At the present time, overall, he is doing quite well clinically. We will discontinue the hinged knee brace. He will continue with outpatient physical therapy to work on range of motion and strengthening exercises as well as endurance. He is allowed to return to work, light duty, no heavy lifting. He will need frequent rest periods. We will see him back in three months’ time for repeat clinical evaluation. No x-rays needed at that time.
