Pain Neurosurgery SOAP Note Transcription Sample Report
SUBJECTIVE: The patient is 10 days status post right L5-S1 laminoforaminotomy for a right L5-S1 herniated nucleus pulposus. He comes today for suture removal stating that he had some mild irritation. He denies any significant wound drainage, has had some mild serosanguineous drainage from the incisional site. He denies any fevers, chills or sweats. His leg pain is much improved. He has had occasional twinges. He has not taken any pain medication in the last week. He has returned to work. He has not done any heavy lifting. Overall, he feels quite well.
OBJECTIVE: Today, he is in no acute distress. There is some mild sanguineous drainage on the dressing. There is some erythema around the incisional site. All sutures were prepped with iodine and removed without difficulty. At the most superior aspect of the incision, there was some mild dehiscence of the wound. There was no purulent material present. There was no edema present. This area was palpated. There was no depth of the wound. This area was prepped at the depth with iodine, and 3 Steri-Strips were applied to reapproximate this area.
ASSESSMENT AND PLAN: The patient is 10 days status post diskectomy at the right L5-S1 level. Neurologically, he is doing quite well. In terms of the incision, we did recommend he keep the Steri-Strips that were reapproximating the most superior aspect of the wound clean and dry for the next 5 to 7 days. Then, he can get them wet in the shower and they should fall off on their own.
We encouraged him to call us with any changes to the incisional area. We have also given him a prescription for Keflex 500 mg p.o. q.i.d. for the next 7 days. This will be called in to his pharmacy. If he has any other questions or concerns, he should contact Neurosurgery. He should remain at the current level of activity at this time, avoiding heavy lifting greater than 5 pounds, bending or twisting. We will advance his activity at his next followup visit.
Sample #2
SUBJECTIVE: This is a pleasant (XX)-year-old female evaluated for complaints of neck and right arm pain. Since that time, she has been treated with a steroid taper as well as physical therapy treatment. She has nearly completed her course of physical therapy. She continues to have right arm pain and paresthesias. This in fact progressed since our initial visit. She has been taking naproxen and Flexeril for her symptoms. She states that her pain is somewhat improved; however, she does have persistent paresthesias in the arm. She does feel subjectively weak in the arm as well. She states that her symptoms come and go in the arm; however, when she hangs her arm forward, she does get paresthesias down the right lateral aspect of her deltoid into her forearm and into her thumb. She also has paresthesias at present in this distribution.
She states initially she was unable to sleep due to the severe pain. Now, she is able to sleep. Again, she is taking naproxen and Flexeril twice daily. She does feel that physical therapy is helping. She did also feel that the Medrol Dosepak was helpful. In addition, she also complains of increasing dysphagia in the last two weeks. She did have an MRI performed a few days ago, which she brings for review today. She denies any bowel or bladder incontinence. She denies any lower extremity symptoms.
OBJECTIVE: Today, the patient is moving upper and lower extremities with 5/5 strength. Sensation intact in the upper and lower extremities. Deep tendon reflexes were normoreflexic. There were no beats of clonus present.
DIAGNOSTIC DATA: Review of the patient’s cervical MRI does show evidence of a disk herniation present at the C5-C6 level pressing on the right C6 nerve root. This also has some mild cord encroachment without cord signal change. Incidentally noted on this scan was T2 hyperintensities measuring approximately 5 mm within the inferior pole of the left and right thyroid lobes, most likely representing cystic structures.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with right C5-C6 disk herniation encroaching on the right C6 nerve. She does have associated radiculopathy symptoms that have been present for over 6 weeks. She has completed Medrol Dosepak and physical therapy and continues to have numbness and tingling and pain down the arm. We do feel that evaluation by his surgeon is warranted at this time.
We will give her a note to return to work on light duty until she is evaluated by her next available spine surgeon. In addition, given the incidental finding of a thyroid cyst and her recent dysphagia in the last two weeks, we will have her set up to see her primary care physician for further evaluation in regards to these findings.
