SUBJECTIVE: The patient has had a biopsy from her left nose, which showed actinic keratosis. The lesion, however, continues to recur. She was being treated with liquid nitrogen in the past. She has also noted a rough area below her left lower lip.

OBJECTIVE: She has a small rough scaly macule on the left side of the nose and other on the left lower lip. The area on the nose is just above the biopsy site.

ASSESSMENT: Actinic keratosis.

PLAN:
1. Recommended to treat with light Efudex cream twice daily for 3 weeks on both lesions.
2. Asked to call me if lesion recurs.
3. She was warned about hypopigmentation.

Sample #2

SUBJECTIVE: The patient is an (XX)-year-old woman who comes for followup of basal cell carcinoma to left thigh treated in January (XXXX). She has noted a rough area on the left nose but no other skin, hair, nail complaints. She did have a small stroke in July from which she has recovered.

OBJECTIVE: Full exam done. She has a well-healed scar on the left thigh. Her skin is clear. No lesions appreciated with the exception of a rough scaly papule on the left nose. She has scattered seborrheic keratosis also.

ASSESSMENT:
1. Actinic keratosis, left nose. This is treated with liquid nitrogen spray.
2. History of basal cell carcinoma left thigh, January (XXXX).

PLAN:
1. She will return in one year’s time.
2. Lesion will be also treated with cryosurgery.

Sample #3

This is a (XX)-year-old gentleman with a history of squamous cell carcinoma on his lip a year ago who returns for a skin exam. No lesions on his skin he is concerned about. He denies itching, pain or bleeding at any skin lesion.

MEDICATIONS: Atenolol, lisinopril, and hydrochlorothiazide.

ALLERGIES: NONE KNOWN.

Review of systems, social history, family history is being updated per the patient information sheet placed in his medical record.

OBJECTIVE: On examination of the face, neck, chest, abdomen, back, upper and lower extremities, hands and feet bilaterally, there are rough keratotic 2-4 mm macules on both cheeks in 4 locations altogether. The rest of the skin exam is unremarkable.

ASSESSMENT: Actinic keratoses.

PLAN: Liquid nitrogen, 10 seconds, for destruction of actinic keratoses. Continue sun screen. She is to followup in 1 year.

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SUBJECTIVE: The patient is a (XX)-year-old woman who returns for followup of rosacea and because of history of lichenoid keratosis. The patient reports that once every couple of months, the rosacea flares. She then started to use Noritate cream and sodium sulfacetamide, and within a month, she reports it has calmed down. The patient does not use the medications on a regular basis. Moderate sun exposure. She does use sunscreen for outdoor activities.

OBJECTIVE: The patient is alert and oriented x3. On examination of her face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, there are no worrisome pigmented lesions or other lesions worrisome for cutaneous malignancy. Face shows mild erythema on the forehead and cheeks.

ASSESSMENT: Mild rosacea, history of actinic keratosis.

PLAN: We discussed with the patient that she will see fewer flares of the rosacea if she uses the metronidazole 0.75% cream daily. The patient can increase to b.i.d. if it does flare. She can continue with the sodium sulfacetamide daily on a p.r.n. basis. Follow up in one year.

Dermatology SOAP Note Example 2

SUBJECTIVE: The patient is a (XX)-year-old woman who returns four weeks after beginning narrow-band UVB for chronic eczema. The patient’s eczema worsened significantly as she was tapering prednisone. She is now back to 20 mg prednisone daily; it had been tapered down to 7.5 mg. The patient is using clobetasol ointment on her skin. She does note that the itchiness has lessened, but she does not think the eczema has improved since she started phototherapy. She is presently on prednisone 20 mg daily, clobetasol ointment daily, hydroxyzine 10 mg q. 6 hours, betamethasone valerate lotion to the scalp, and desonide cream to the face p.r.n.

OBJECTIVE: The patient is alert and oriented x3. There are erythematous, slightly lichenified coalescing papules on the upper mid back, abdomen, proximal thighs, and arms. Face is clear.

ASSESSMENT: Chronic eczema.

PLAN: The patient will continue with the narrow-band UVB for an additional four weeks. We discussed with the patient if at that point she really has not had any improvement in her eczema, then it is unlikely that continuing phototherapy is going to be beneficial. We discussed with her again today that the phototherapy is not curative, but can have an additive benefit through other medications in managing the eczema. The patient voiced understanding of this, and she will continue with the narrow-band UVB three times weekly. Followup will be in four weeks.

Dermatology SOAP Note Example 3

SUBJECTIVE: The patient is a (XX)-year-old gentleman who returns for skin examination because of a history of basal cell carcinoma. He questions raised moles on his back, chest, legs; all of these are asymptomatic.

OBJECTIVE: The patient is alert and oriented x3. On examination of his face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, he has sebaceous hypertrophy diffusely on the dorsal and distal aspect of the nose. There are no inflammatory papules or pustules seen. There are multiple tan brown and gray stuck-on keratotic papules and plaques widely scattered on the back, chest, and legs; none with worrisome features.

ASSESSMENT: Multiple seborrheic keratoses. No sign of new basal cell carcinoma, rosacea with rhinophyma changes.

PLAN:
1. The patient wants to try stopping the tetracycline. We discussed with him the rosacea may have remitted. On the other hand, we discussed with him if he does start developing new areas of redness, pustules on the nose, would recommend resuming the tetracycline 500 mg p.o. b.i.d. He voiced understanding of this. He was given a written prescription, so can restart the medication if needed.
2. Reassurance regarding all of the other skin lesions he questions. Follow up again in one year because of a basal cell carcinoma.

Dermatology SOAP Note Example 4

SUBJECTIVE: The patient is a (XX)-year-old woman who returns for followup of hand eczema. She is very pleased with the improvement in her skin and has no other complaints regarding her skin today.

OBJECTIVE: The patient is alert and oriented x3. Palmar surface of right, greater than left hand, shows mildly erythematous, dry patches and similar changes on the dorsal surface of several of the fingers.

ASSESSMENT: Atopic eczema with component of chronic irritant contact dermatitis, improved.

PLAN:
1. Encouraged her to continue and increase moisturizer as her skin is still quite dry.
2. Continue with the mometasone ointment b.i.d. to the eczematous areas.
3. We discussed with her if it becomes severe, she can resume the clobetasol ointment, but not for longer than two weeks continuously. Followup is p.r.n.

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OBJECTIVE: The patient is a thin gentleman, in no distress. WT: 128. P: 116. BP: 118/66. RR: 20. Saturations on 1.5 liters 93%. HEENT: He has mild temporal wasting. Pupils are equal and reactive. Nares have no lesions or exudates. There is no dried heme. Oral cavity has no lesions or exudates. Neck: Supple. Cardiac: PMI is not appreciated. Regular, S1/S2. Lungs: He is hyperresonant to percussion. He has moderately diffusely decreased breath sounds with no wheezing or rales. Abdomen: Soft and nontender. Extremities: No edema.

ASSESSMENT: The patient has right upper lobe pneumonia with extensive smoking history and likely chronic obstructive pulmonary disease, shortness of breath, mild cough and hypoxemia.

PLAN: The patient needs a followup chest x-ray to make sure that the infiltrate has cleared. If not, he will need a CT scan. He needs a check of his overnight oximetry and a 6-minute walk on his O2 to assure adequacy of his O2 needs, and he needs PFTs. As we were leaving, his daughter complained of him having some epistaxis. We added humidity to his O2 and gave him saline nasal spray. Follow up after the aforementioned studies, and they understand and agree with the plan.

Pulmonary SOAP Note Medical Transcription Sample Report #2

SUBJECTIVE: The patient is here for a followup. She had her surgery on her shoulder and had it replaced again and is feeling pretty good. She is dyspneic with activity and talking too much. Other than that, she has no new complaints.

OBJECTIVE: WT: She has gained 8 pounds. P: 74. BP: 114/64. RR: 22. Saturations on 3 liters initially 86% and with rest 94%. HEENT: She has no lesions or exudates. Neck: Supple. Lungs: She has mildly decreased breath sounds with no wheezing or rales. Cardiac: Regular, S1/S2. Abdomen: Benign. Extremities: She has +1 ankle edema, and her scar on her right shoulder is healing well.

DIAGNOSTICS: Her chest x-ray from the hospital showed no acute cardiopulmonary disease. She does have COPD, and the right upper lobe infiltrate has resolved.

ASSESSMENT: She has chronic obstructive pulmonary disease with atrial fibrillation, congestive heart failure intermittently with dyspnea, hypoxemia, bronchiectasis, and she is status post shoulder replacement.

PLAN: We told her to follow up with Dr. Jane Doe. We will continue O2. We started her on Spiriva. We told her to hold off on her Atrovent to see how she does with that. We will see her back in 3 months. She knows to call if there is any change in her pulmonary symptoms.

Pulmonary SOAP Note Medical Transcription Sample Report #3

SUBJECTIVE: The patient is here for a followup of her PFTs. She continues to complain of excessive daytime somnolence and fatigue. She said she used to snore but is better on the oxygen therapy. Other than that, she has no new complaints of any kind. She does have achy legs at times.

OBJECTIVE: WT: She has gained a little bit of weight, up to 204 pounds from 198. P: 88. BP: 134/82. RR: 20. Saturations on room air 94%. HEENT: Unchanged from her prior visits. Neck: Supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign, but obese. Extremities: No edema.

DIAGNOSTICS: Her PFTs showed just a very mild decrease in her TLC and FVC from several years ago, and her overnight oximetry on 2 liters shows no significant desaturations.

ASSESSMENT: She has moderate pulmonary hypertension with vocal cord nodules and hoarseness, hiatal hernia, abnormal PFTs, chronic anemia, and known mild obstructive sleep apnea.

PLAN: I am going to recheck her polysomnography to see if there is anything else that could be contributing to her symptoms. If so, then we will intervene on that level. I am going to get a 6-minute walk. I will consider doing a followup CT scan after we recheck her lung volumes in 6 months and follow her a little more closely. She understands and agrees with the plan.

Pulmonary SOAP Note Medical Transcription Sample Report #4

SUBJECTIVE: The patient is here for a hospital followup. She is feeling pretty good. She was hospitalized for shortness of breath, cough and bronchospasm. She did well with inhaled bronchodilators and steroids and was discharged to home in several days. She has had similar episodes, which at times were produced by extreme stress. She took some Advair for a while and then took some Foradil. She has been off of everything for a couple of weeks, and she is feeling pretty good. She is still fatigued, but other than that, she is doing well.

OBJECTIVE: She looks okay. WT: 160. P: 74. BP: 132/70. RR: 18. Saturations on room air 97%. HEENT: She has no lesions or exudates. Neck: Supple without adenopathy. Lungs: Clear to A/P. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: She has mild asthma with exacerbation of allergic rhinitis, mostly manifesting as a horrific cough and some palpitations also contributing to things.

PLAN: At this point in time, we would like to check some PFTs to see if she needs to be on some type of maintenance therapy. We discussed the rationale of this with her. She understands and agrees, and we will see her back after those.

Pulmonary SOAP Note Medical Transcription Sample Report #5

SUBJECTIVE: The patient is here for a followup. She has found out she is diabetic, but other than that, she is doing well. She occasionally has cough and dyspnea on exertion, but she is doing okay. She has no new complaints at this time.

OBJECTIVE: She looks good. WT: 168. P: 100. BP: 146/76. RR: 18. Saturations on room air 94%. HEENT: Unchanged from her prior visit. Neck: Supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

DIAGNOSTICS: CT scan shows no changes.

ASSESSMENT: She is status post right upper lobectomy for lung carcinoma T2 versus T3N1M0 with hypoxemia, adenopathy that is unchanged, chronic obstructive pulmonary disease, and a new diagnosis of diabetes mellitus.

PLAN: We will see her back in 6 months, but we will get a CT scan in a year unless the medical oncologist or radiation oncologist would like it sooner.

Pulmonary SOAP Note Medical Transcription Sample Report #6

SUBJECTIVE: The patient is here for followup. He is tolerating the BiPAP. He did well on that. He is complaining of increasing shortness of breath, cough and productive phlegm. He has a little bit of an infiltrate on his chest x-ray. He has no other fevers, chills or sweats. He actually is feeling a little bit better.

OBJECTIVE: WT: 242. P: 62. BP: 128/64. RR: 24. Saturations on room air 93%. HEENT: He has no lesions or thrush. Neck is supple without adenopathy. Lungs: He has a few coarse rhonchi in the right lung. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: He has right upper lobe pneumonia with abnormal sputum, obstructive sleep apnea with RDI of around 25, history of tracheal stent, coronary artery disease, myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus and peripheral vascular disease.

PLAN: Today, we put him back on his inhaled tobramycin for 2 weeks, Levaquin 500 mg a day for 14 days. We will check a chest x-ray in 2-3 weeks. We will see him back then and then we will readdress his sleep issues, and he will need an overnight oximetry on the BiPAP.

Pulmonary SOAP Note Medical Transcription Sample Report #7

SUBJECTIVE: The patient is here at Dr. John Doe’s request. She has been coughing, short of breath since Friday. She said she got it flared up by someone’s perfume. She was better on Saturday. 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 examination today, she is coughing, dyspneic. WT: She is not weighed. P: 114. BP: Pending. RR: 22. Saturations on room air 97%. 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, was secondary to her underlying asthma, allergic symptoms, and a prolonged QT. She just saw Dr. Jane Doe today and there is no concern with that.

PLAN: She needs the 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. I gave her prednisone burst and taper. I will see her back next week. If her symptoms worsen or she does not improve, she needs to go to the emergency room. She understands that.

Pulmonary SOAP Note Medical Transcription Sample Report #8

SUBJECTIVE: The patient is here for followup. He has a little dyspnea on exertion. We checked his oxygen saturations on room air, and at rest, they are 85%, so he is on his O2. He has no new symptoms or increasing chest pain or cough. He is complaining of allergies and had congestion and sinus pain at times.

OBJECTIVE: On examination, he looks good. WT: 160. P: 96. BP: 104/64. RR: 20. Saturations on room air 94%. HEENT: He has no lesions or exudates. He has deviated septum. Lungs: He has mildly decreased breath sounds but clear. Cardiac: Regular. Abdomen: Benign. Extremities: DJD but no edema.

DIAGNOSTICS: His 6-minute walk showed his room air saturations at rest were 85%.

ASSESSMENT: He has hypoxemia, mild chronic obstructive pulmonary disease, lung carcinoma, non-small cell in the right hilum status post XRT and chemotherapy. He had staging scans again today, and he has chronic sinus disease, and this was seen on the MRI of his brain.

PLAN: We will continue his O2. We put him on Flonase. We will see him back in 4 months. We requested a copy of the scans that were done today.

Pulmonary SOAP Note Medical Transcription Sample Report #9

SUBJECTIVE: The patient is here for followup. She is having a really hard time wearing the CPAP. She knows, but she does not wear it. She has got a headache. She is tired. She wants to sleep on her stomach and it is just not seeming right. She only needs a new mask and she has not done that. We talked for a long period of time about different interventions from surgical to weight loss to repeating the study, all different kinds of options.

OBJECTIVE: WT: 200. P: 80. BP: 138/86. RR: 18. Saturations on room air 95%. HEENT: Unchanged from her last visit. She has a stage III oropharynx. Neck is supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: She has obstructive sleep apnea with excessive daytime somnolence and tiredness, also some mild cognitive impairment, chronic sinusitis, and temporomandibular joint dysfunction.

PLAN: We reviewed with her surgical options, weight loss of 40 pounds, repeat PSG. She is going to think about all those. In the meantime, we will check an overnight oximetry on room air. She will check for surgeons in her area because she has moved. We will see her back in 8 weeks.

Pulmonary SOAP Note Medical Transcription Sample Report #10

SUBJECTIVE: The patient is here for followup. She is doing pretty good except she threw her back out, and she has been taking some Ultracet for that. It has been helping. She has a little bit of postnasal drip. Her breathing is otherwise unchanged. She does have a little bit of tightness at night. I reviewed her PFTs with her.

OBJECTIVE: WT: 214. P: 86. BP: 140/84. RR: 18. Saturations on room air 97%. HEENT: Unchanged from her prior visits. Neck is supple without adenopathy. Lungs: Clear. Cardiac: S1 and S2. It is irregular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: She has got mild pulmonary hypertension secondary to mitral stenosis, status post mitral valve replacement with atrial fibrillation. Her PFTs show restrictive impairment with mild asthma, which persists with a good response to bronchodilators.

PLAN: We will check yearly PFTs. I put her on albuterol MDI p.r.n. because of her chest tightness at night, told her to start with 1 puff. I will see her back in 6 months. She knows to call if there is any change in her pulmonary symptoms. I gave her some Ultracet to take as needed for her back pain. She does not want any intervention at this time because she has had that in the past.

Pulmonary SOAP Note Medical Transcription Sample Report #11

SUBJECTIVE: The patient is here for followup. He is actually doing fairly well and overall little bit improved, I think, on even the lower dose of prednisone. This is the best he has felt in a while. He has no new pulmonary complaints.

OBJECTIVE: On exam today, he looks good. WT: 196. P: 72. BP: 170/88. RR: 20. Saturations on room air 96%. With rest, his saturations are at 98%. HEENT: Unchanged from his last visit. Neck is supple. Lungs: He has a few Velcro rales at the bases. Cardiac: Regular. Abdomen: Benign. Extremities: DJD.

ASSESSMENT: He has interstitial lung disease/idiopathic pulmonary fibrosis with bronchiectasis, dyspnea, hypoxemia, and atrial fibrillation.

PLAN: Until the (XX)st of March, we are going to go with the prednisone 10 mg every other day. When he comes back, we will probably check PFTs and a CAT scan. If he gets worse or more short of breath, we told him to go up to one a day. He knows to call if there is any change in his pulmonary symptoms. We will see him back in the fall.

Pulmonary SOAP Note Medical Transcription Sample Report #12

SUBJECTIVE: The patient is here for followup of his polysomnography. He has had really no change since last visit. His wife just continues to complain that he snores quite loudly. He wakes up very frequently. He sleeps on his right side for the most part of time, and he has no other new pulmonary complaints.

OBJECTIVE: WT: 208. P: 72. BP: 126/78. RR: 18. Saturations on room air 95%. HEENT: He has no changes. He has a very small left nasal passage. It is very difficult to visualize. Oral cavity has a stage II-III oropharynx. Neck is supple. Lungs: Clear. Cardiac: Regular. Remainder of his exam is unchanged.

DIAGNOSTICS: His polysomnography showed a very mild OSA with an RDI of 5.7 with mild snoring rated at 5.

IMPRESSION: He has mild obstructive sleep apnea with a deviated nasal passage, history of coronary artery disease, peripheral vascular disease, and according to his wife, he has loud snoring with questionable witnessed apneas.

PLAN: We discussed everything with him. We actually think that he may benefit from an ENT evaluation because of his snoring. He does not really have a lot of symptoms of excessive daytime somnolence and fatigue. To that end, we put a consult into an otorhinolaryngologist who will take his insurance. We put him on some Flonase. We will see him back in 3 months.

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Additionally, she does have some pain, which is currently controlled with her current regimen. She is tolerating her liquid diet well. Her oral ulcers are not causing her problem at the moment. Her Magic mouthwash has been controlling her oral discomfort. Otherwise, she has no other complaints. No swelling, headache. She slept well last night. She actually reports that her energy is improved. She feels mildly confident that she can go home today.

OBJECTIVE:
VITAL SIGNS: Temperature is 98.2, blood pressure 112/64, pulse 69, respirations 18. She is saturating 100% on room air.
GENERAL: The patient is awake, alert and oriented x3. She is sitting up in bed, conversant appropriately and responding appropriately to questions. She is in no apparent distress.
HEENT: Sclerae are anicteric. Mucous membranes are moist. Oral lesions do persist. They are unchanged. No jugular venous distention or physical pulsations appreciated on exam. No masses.
HEART: Normal S1, S2. Did not appreciate any murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
ABDOMEN: Soft, nondistended, nontender to palpation. Bowel sounds are present in all quadrants.
EXTREMITIES: No peripheral edema appreciated. Dorsalis pedis pulse is 2+/4 bilaterally, symmetrical.

LABORATORY DATA: BMP demonstrates glucose 100, BUN 21, creatinine 1.12, sodium 140, potassium 4.7, chloride 107, carbon dioxide 26, calcium 8.2. CBC demonstrates white count 4.0, hemoglobin 10.6, hematocrit 32.2, MCV 80.3, platelets 91. She has a normal differential.

The hemoglobin reported on the CBC was drawn at 5:30 this morning. She had a hemoglobin drawn last night as well with a hemoglobin of 10.7. She is maintaining her blood counts.

ASSESSMENT AND PLAN:
1. Acute blood loss anemia secondary to internal hemorrhoids. The patient has had no more bloody bowel movements since being transferred from the ICU. She does have some mild spotting with 1 bowel movement, but this is not the volume reported upon presentation. Colorectal surgery is coming by to evaluate. Gastroenterology has also been made aware of her readmission.
2. Presyncope secondary to acute blood loss anemia. The patient has had no more presyncopal symptoms. She denies any lightheadedness or dizziness upon standing. She has ambulated to the bathroom without difficulty.
3. Hepatocellular carcinoma with metastases to lung. The patient continues to receive Avastin monthly. She has been continuing her erlotinib p.o. daily. She does not have any currently, but her son is bringing her some today.
4. Internal hemorrhoids, status post transanal hemorrhoidal dearterialization. Colorectal is evaluating the patient. Her bleeding is stable. She is using Proctofoam 3 times daily as needed.
5. Insulin-dependent diabetes mellitus. The patient’s sugars are controlled. Continue her basal and sliding scale insulin per her home regimen.
6. Essential hypertension. Her blood pressure is controlled. Continue current management.
7. Dyslipidemia. Continue her statin.
8. Oropharyngeal mucositis secondary to her chemotherapy. Continue Magic mouthwash as needed. Acute pain controlled on the current regimen.
9. Nausea. She says she has controlled with the Zofran sublingually. Continue.
10. Portal hypertensive esophageal varices, nonbleeding.
11. Deep venous thrombosis prophylaxis. Continue PCDs.
12. Code status. The patient still is a full code.

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SUBJECTIVE: The patient is a 3-year-4-month-old previously healthy male who presents with a 3-day history of nasal congestion and cough. According to him and mom, he began having nasal congestion initially and the snot became more green on the day of presentation. He has also been fussy today and has had decreased appetite only today.

Mother reports that he has been drinking well. He has had good urine output. No change in stool. He has had no vomiting; although, he did complain of mild abdominal pain today, earlier in the day, that has since resolved. He has also had cough, which mother says that although he has had no mucus production with the cough, it has sounded “wet.” He has been afebrile through this course and has no known sick contacts; although, he is in preschool 3 days per week.

The patient has a history of viral-induced wheezing and has been given an albuterol inhaler in the past. They have not been using the inhaler with his cough because mother says that it does not sound the same as when he was originally prescribed the inhaler. His last use of the inhaler was about 2-3 weeks ago. He does take Flonase and Zyrtec every evening for allergies and is continued on these medications. Mother has given him no other medicines with the current illness.

PAST MEDICAL HISTORY:
1. Viral-induced wheezing.
2. Allergic rhinitis.

ALLERGIES: No known drug allergies.

OBJECTIVE:
VITAL SIGNS: Temperature 97.6, heart rate 106, respiratory rate 30, blood pressure 88/60, weight 15.6 kg, which is 57th percentile for age; height 96.5 cm, which is 24th percentile for age, for a BMI of 16.8, which is 81st percentile for age.
GENERAL: Awake, alert, sitting in a chair in the exam room next to mother, pleasant and interactive throughout the exam.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, reactive to light. Conjunctivae are clear without injection or exudate. Nares patent with some erythema and swelling of the turbinates and some obvious nasal crusting. Oropharynx with mild erythema of the posterior oropharynx. No exudate. TMs clear on the right without signs of effusion. Left is slightly more dull but no obvious effusion.
NECK: Supple with shotty cervical lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. Good breath sounds bilaterally, not tachypneic. No flaring. No respiratory distress, no retractions.
HEART: Normal rate, regular rhythm. No murmurs.
ABDOMEN: Soft, nontender, nondistended. No hepatosplenomegaly or mass.
SKIN: No rashes.
EXTREMITIES: Moves all extremities well. DP pulses 2+ bilaterally. Capillary refill less than 2 seconds peripherally.

ASSESSMENT: The patient is a 3-year-4-month-old male with 3 days of rhinorrhea and cough without fever consistent with a viral upper respiratory infection.

PLAN:
1. Continue supportive care including good oral hydration and Tylenol or Motrin for fever or pain.
2. Described to mother that symptoms are currently consistent with a viral upper respiratory infection; however, a bacterial infection could develop. She was given signs to look for further progression of symptoms, including prolonged fever, respiratory distress and inability to tolerate p.o.
3. Recommended followup as needed for worsening symptoms or next scheduled well-child check. Recommended continuation of Flonase and Zyrtec as previously prescribed.

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She has had no further episodes of presyncope or syncope. She is trying to take fluid and salt liberally. Her tremor is present mildly and only intermittently. It is primarily in the right hand. She continues to do tai chi twice a week and works out on the treadmill twice a week.

She denies depression, hallucinations, delusions, cognitive changes, dysphagia, dysarthria, hypophonia, freezing of gait, falls, sensory changes. She has mild bladder urgency. She also has mild constipation, which improves with the Rancho recipe.

MEDICATIONS:
1. Sinemet 25/100 mg 1-1/2 tablets t.i.d.
2. Naltrexone 5 mg nightly.
3. Coenzyme Q10 1200 mg a day.
4. Vitamin C.
5. Vitamin D.
6. Melatonin.
7. DHEA.
8. Memory Essentials supplement.
9. Magnesium and calcium supplement.
10. Acetyl-L-carnitine.

OBJECTIVE: The patient is a pleasant, well-groomed woman in no acute distress. Blood pressure is 98/60, pulse 78, respiratory rate 18. Affect is appropriate. She has only slight facial masking and much better facial expression today than at last visit. Extraocular movements are intact. Voice is of normal volume. Myerson’s is absent. Tone in the neck is trace increased. There is slightly reduced shoulder shrug on the right. There is a moderate amplitude intermittent rest tremor in the right upper extremity, which is infrequently present and less than the last exam. There is just a slight action tremor in the right upper extremity as well.

She has mild rigidity in the right upper extremity scored as a 1 on the UPDRS scale. On the left, she has just slightly increased tone in the left upper extremity scored as a 0.5. She has very mild bradykinesia bilaterally scored as a 1 on the right and a 0.5 on the left. Toe tapping is intact bilaterally. She rises from a chair easily without using her arms. Posture is erect. There is slight re-emergent tremor in the right upper extremity when she walks. Arm swing is intact. Pull test is negative.

Autonomic reflex testing revealed orthostatic changes with tilt of the bed. Supine blood pressure during the test was 126/62. When head was tilted up, blood pressure initially reduced to 118/66 with a heart rate of 96. Seven minutes tilt up, her blood pressure was 112/68 with a heart rate of 96. She complained of nausea at that time. It was found that she had an abnormal autonomic reflex study with evidence of cardiovagal dysfunction. There was also mild abnormality in sweat noted. There was no evidence of postganglionic sudomotor sympathetic function or adrenergic cardiovascular function.

ASSESSMENT AND PLAN: This is a (XX)-year-old woman with Parkinson’s disease and orthostasis.
1. Parkinson’s disease: She has really been doing quite well with a slight increase in her dose of Sinemet, and we would like her to continue on Sinemet 25/100 mg 1-1/2 tablets t.i.d.
2. Orthostasis: Though she has been asymptomatic since I saw her last, she continues to have low blood pressures, and tilt table test does show evidence of orthostatic changes. Given the fact that the Parkinson’s disease and the Sinemet combined can conspire to lower blood pressure further and in the future she will likely need increase in her dose of Sinemet, we would like her to start midodrine. She will start at 2.5 mg in the morning and increase after 1 week to 2.5 mg in the morning and 2.5 mg at noon. She will follow up with me in four months.

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CHIEF COMPLAINT: Sore throat.

SUBJECTIVE: The patient is complaining of sore throat for a few days. She has a bad cough and stuffy nose. No fever. Her sister was just diagnosed with strep and dispensed a course of amoxicillin. She has had an ear infection in the past.

OBJECTIVE: The patient is ambulatory. She appears well. She is not in any distress. Her temperature is 98. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose is clear. Mouth is clear. There is no tonsillopharyngeal redness. There is no neck gland enlargement. Chest and lungs are clear. Heart: Normal. Abdomen: Benign. Skin: No rash.

ASSESSMENT: Upper respiratory infection and pharyngitis, most likely viral.

PLAN: Rapid strep test will be done and a throat culture will be sent to rule out the possibility of strep. Meanwhile, management is supportive and symptomatic.

Sample #2

CHIEF COMPLAINT: Sore throat.

SUBJECTIVE: The patient has a cough and a cold for about 1-1/2 weeks now that is clearing up, but yesterday and today, his nose was very runny. His neck glands are enlarged. Mom looked into his throat, his throat was red, and there were some white fine spots. He was exposed to a friend who had strep on Saturday. He had pneumonia last year. He does not have asthma.

OBJECTIVE: The patient is awake, alert, not in distress. Temperature is 100. HEENT: Both tympanic membranes are kind of reddish. He is nasally congested. Mouth is clear. There is moderate redness of the tonsillopharyngeal area, and there are some fine spotty exudates on the tonsils. Neck glands, anterior cervical glands are enlarged. Neck is supple. Chest and Lungs: Clear. Heart: Normal. Skin: No rash.

LABORATORY DATA: Rapid strep test was done and that is positive.

ASSESSMENT: Acute strep pharyngitis, upper respiratory infection.

PLAN: The patient will be treated with amoxicillin 250 mg/5 mL. He will take 2 teaspoons 3 times daily for 10 days.

Sample #3

CHIEF COMPLAINT: Sore throat.

SUBJECTIVE: The patient is a (XX)-year-old female with past medical history significant for asthma, coming for a brief office visit today. According to the patient, she is having sore throat for the last 2 to 3 days. It hurts to swallow. She does not give any history of fever. Now, she has trouble breathing. She has occasional cough. She has been wheezing. The cough is mostly dry in nature. She has been using the inhaler. So far, she has been taking some Motrin over-the-counter.

OBJECTIVE: On examination today, she is afebrile. Her blood pressure is 136/84, heart rate is 90, weighs 243 pounds, current temperature 98.2. Pain is 4/10 in intensity. HEENT: Bilateral eardrum partially visualized because of the wax, appeared normal. Oral mucosa moist. Minimal erythema to posterior pharynx. No exudate seen. Nasal mucosa: Moist. No congestion. No sinus tenderness. No lymphadenopathy. Lungs: She has diffuse scattered wheezing. Heart: S1, S2 normal. Regular rate and rhythm. The patient’s O2 saturation is 97% on room air.

ASSESSMENT AND PLAN: This is a (XX)-year-old female with a sore throat, asthma exacerbation. We will start with a rapid strep. The patient received albuterol nebulizer during the office visit. The wheezing did improve. Given the excellent saturation, we will hold off on the x-ray for now. We will treat with amoxicillin and a prednisone taper. The patient recently was treated with a Z-Pak. Anytime there is worsening or shortness of breath/wheezing, she is to contact the office.

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SUBJECTIVE: The patient comes in today with a slightly tender spot on the left helix of the ear. He notes that it is sore a little bit at night when he sleeps on it, but not appreciably so. He noted it first at the end of March and just wants to make sure it is harmless and not a cancer. Other than it being tender, he has no other symptoms related to this, and he has not treated it in any way.

OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included his left ear.

ASSESSMENT AND PLAN: Rule out chondrodermatitis nodularis helicis versus actinic keratosis. On the left helix, he had a crusty scaly patch that was about 2 mm in diameter, and the lesion was numbed with lidocaine/epinephrine and a shave biopsy was done to rule out actinic keratosis. If it is negative for actinic keratosis, we discussed with him that he can simply leave it, or if he becomes too symptomatic, we certainly could try to inject it with Kenalog.

We will see him back in Dermatology on an as-needed basis.

Dermatology SOAP Note Sample #2

SUBJECTIVE: The patient is a (XX)-year-old gentleman who comes in today for a skin check and also psoriasis check. He had psoriasis on the last visit, on his right palm, and he also notes a spot on his right thumb that he tends to pick at and is always a little bit fissured, but he is not using any medication on this. The last time I saw him, he noted it did not bother him, so although he had some triamcinolone at home, he was not using it. He notes today that his lower legs itch and, in particular, the normal skin on lower leg itches rather than a red, rashy skin that I see today. He also notes he has multiple brown spots on his trunk and wants me to check them.

OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the scalp, face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.

ASSESSMENT AND PLAN:
1. Psoriasis: He had three pink scaly patches on his lower legs consistent with psoriasis, and I am going to give him Lidex ointment to apply twice a day to these patches. Also, on his hand, he had some hyperkeratosis of the palm as well as fissuring on his right thumb and this is also consistent with psoriasis. I am going to have him use the Lidex there as well.
2. Itchy legs and dry skin: On his lower legs, he had some dry skin in addition to the patches of psoriasis. I discussed he can use Sarna lotion as needed and Cetaphil or Eucerin moisturizing lotion there as well.
3. Seborrheic keratosis: On his trunk, he had multiple brown plaques consistent with benign seborrheic keratoses. No treatment needs to be done.

We will see him back in six months in Dermatology to check his psoriasis.

Dermatology SOAP Note Sample #3

SUBJECTIVE: The patient is a (XX)-year-old woman who comes in today for a skin check. Her last one was on MM/DD/YY. She has had a basal cell skin cancer on left chest on MM/DD/YY and then, in YYYY, she had a squamous cell carcinoma in situ on her nose. She has no new or changing lesions she is concerned about today. She is battling stomach cancer and is in remission currently. She has had metastasis to the lungs with resection of that in the past.

OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the scalp, face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.

ASSESSMENT AND PLAN:
1. History of basal cell skin cancer and squamous cell carcinoma in situ on her left chest and left nose: She had no evidence of recurrence in the scar site of each of these areas.
2. Nevi: She had a few brown macules and papules scattered on torso and extremities with none concerning for malignancy.

We will see her back in Dermatology in a year.

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CHIEF COMPLAINT: Pulmonary hypertension with an estimated pulmonary artery systolic pressure of 50-60 on recent echocardiogram, hypertrophic nonischemic cardiomyopathy with normal systolic function, home oxygen therapy 3 liters at rest, 4 liters with activity starting today.

SUBJECTIVE: The patient is a very pleasant (XX)-year-old woman who we see for what we thought was chronic obstructive pulmonary disease and pulmonary hypertension, which was recently diagnosed on an echocardiogram. We walked her in the hall today, and her oxygen saturation did drop down to 86% on 3 liters of home oxygen. Therefore, we have recommended that she use oxygen 3 liters at rest and 4 liters with activity.

Her chest x-ray looks like she has some congestion on it when I checked it last. We recommended that she continue her Lasix 60 mg twice daily and watch her salt intake.

Her pulmonary hypertension stems from the fact that this echocardiogram, from last month, shows an estimated pulmonary artery systolic pressure of 50-60. This was not mentioned on a previous echocardiogram from two years ago. I am wondering if she is fluid overloaded. Her BNP is over 600. Although it was better than her previous BNP, she may have elevated left-sided pulmonary venous pressures causing her pulmonary hypertension.

We discussed this with her and her family today and they are not interested in having a right-sided heart catheterization at this time. I agree.

OBJECTIVE: Blood pressure 108/62, heart rate 72, oxygen 95%. Chest is clear. Cardiac: Regular rate and rhythm.

ASSESSMENT AND PLAN:
1. Pulmonary hypertension: We will repeat her echocardiogram five months from now, and we will see her the month after.
2. Chronic obstructive pulmonary disease: Her pulmonary function test looked more restricted than obstructed. However, she does have some concavity to the expiratory limb in the flow volume curve. Her vital capacity, however, is low at 54% of predicted. I am wondering if this is secondary to congestive heart failure or if this is real restriction. Her chest x-ray does not show congestive heart failure at this time.
3. Shortness of breath with ambulation: We recommended that she take 2 inhalations of Combivent 20 minutes prior to coming to the doctor. We also recommended that she increase her ambulatory oxygen to 4 liters and use 3 liters at rest.

We will see her back in six months. We will get an echocardiogram in five months and discuss the results of this. When I see her back, she will get a walking oximetry test and pulmonary function test.

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CHIEF COMPLAINT: Urinary retention.

SUBJECTIVE: The patient is a (XX)-year-old gentleman who presented approximately a week ago in urinary retention. He, at that time, had a Foley catheter placed and was discharged to home with the Foley bag to gravity drainage. He returns today for a voiding trial and was found to have a postvoid residual of approximately 830 mL. The patient has had a prior episode of urinary retention in the past, approximately four years ago, and was placed on Cardura at that time.

In addition, the patient states that his PSA, approximately four years ago, was in the level of around 4 or so; however, the patient never had his PSA followed up. He does report that he, in addition, has some difficulty with his urinary stream. He has nocturia approximately only one time per night and he does have occasional incontinence on doing heavy activity or stressful work. The patient denies any urinary tract infection or gross hematuria. His prior episode of urinary retention, four years ago, involved nearly 48 hours without voiding. Actually, the patient did have a prostate biopsy approximately four years ago, which was reportedly negative.

PAST MEDICAL HISTORY: The patient’s past medical history is remarkable for smoking and reactive airways disease requiring an inhaler. The patient has had a right inguinal hernia repair.

MEDICATIONS: Include generic Cardura 8 mg p.o. daily as well as albuterol inhaler, which he uses daily.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: Remarkable for approximately anywhere from 2-4 drinks per day as well as approximately one-half pack per day. He has over a 40-pack-year history of smoking.

FAMILY HISTORY: No significant family history.

OBJECTIVE: On physical exam, he is a pleasant male in no acute distress. Lungs are clear. Heart is regular. Abdomen is soft, nontender and nondistended. He has a well-healed scar in the right groin. His GU exam reveals a circumcised phallus, which is unremarkable. He has bilateral descended testicles, which are also unremarkable and no palpable masses and they are nontender. Rectal exam reveals a 2-3+ prostate.

ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman with a history of urinary retention and benign prostatic hypertrophy who now presents with a failed voiding trial. The plan is to discharge this patient to home again with the Foley catheter, which will remain indwelling until the time of his surgery. He will be, today, scheduled for a TURP since his benign prostatic hypertrophy has resulted in urinary retention refractory to medical therapy. His urinalysis and urine culture, which were checked when he had his Foley catheter placed, were negative. He will, today, undergo a PSA test as well as any preoperative blood work that may be required. He will return and we will see him in the next several weeks for his operation.

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