Soap note 1: Examples of Soap Notes: Writing Soap Notes
CHIEF COMPLAINT: “Hypertension, syncope and spinal stenosis recheck”
The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.
PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS: Reviewed and unchanged from the dictation on 12/08/2019.
MEDICATIONS: Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D three pills daily, multivitamin daily and TriViFlor 25 mg two pills daily. She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.
ALLERGIES: Benadryl, phenobarbitone, morphine, Lasix, and latex.
FAMILY HISTORY / PERSONAL HISTORY: Reviewed. Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She has one brother with asthma.
PERSONAL HISTORY: Negative for use of alcohol or tobacco.
REVIEW OF SYSTEMS:
Bones and Joints: She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg. She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr ABC. She underwent several tests. She did have magnetic resonance angiography of the lower extremities and the aorta which were normal. She had nerve conduction study that showed several peripheral polyneuropathy. She reports that she has myelogram last week but has not got results of this. She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve. Genitourinary: She has occasional nocturia.
Vital Signs: Weight: 227.2 pounds. Blood pressure: 144/72. Pulse: 80. Temperature: 97.5 degrees.
General Appearance: She is an elderly female patient who is not in acute distress.
Mouth: Posterior pharynx is clear.
Neck: Without adenopathy or thyromegaly.
Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.
Heart: Normal S1 and S2 without gallops or rubs.
Abdomen: Without masses or tenderness to palpation.
Extremities: Without edema.
3. Spinal stenosis.
She is advised to continue with the same medication.
She previously had an episode of syncope around Thanksgiving. She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.
She still is being evaluated for this and possibly will have surgery in the near future.
Soap Note 2: Examples of Soap Notes: Writing Soap Notes
CHIEF COMPLAINT: “Downs syndrome”
This 46-year-old white male with Down’s syndrome presents with his mother for follow-up of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil 250 mg tablet once daily without any problems. He is due to have an ALT check today. At his appointment in June, I also found that he was hypothyroid with elevated TSH. He was started on Levothroid 0.1 mg and has been taking that daily. We will recheck a TSH today as well. His mother notes that although he does not like to take the medications, he is taking it with encouragement. His only other medications are some eyedrops for his cornea.
OBJECTIVE: Weight was 149 pounds, which is up 2 pounds. Blood pressure was 120/80. Pulse is 80 and regular.
Neck: Supple without adenopathy. No thyromegaly or nodules were palpable.
Cardiac: Regular rate and rhythm without murmurs.
Skin: Examination of the toenails showed really no change yet. They are still quite thickened and yellowed.
1. Down’s syndrome.
1. Recheck ALT and TSH today and call results.
2. Lamisil 250 mg #30 one p.o. daily with one refill. They will complete the next eight weeks of therapy as long as the ALT is normal. I again reviewed the symptoms of liver dysfunction.
3. Continue Levothroid 0.1 mg daily unless dosage need to be adjusted based on the TSH.
CHIEF COMPLAINT: “Hand dermatitis”
The patient is a 29-year-old African-American female, an established patient of dermatology, last seen in our office on 10/13/20. She comes in today as a referral from Dr. ABC. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.
FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.
CURRENT MEDICATIONS: Claritin 10mg, 1 tablet daily by mouth, and Zyrtec 10mg, 1 tablet daily by mouth
PHYSICAL EXAMINATION: The patient has very dry, cracked hands bilaterally.
IMPRESSION: Hand dermatitis.
1. Discussed further treatment with the patient and her interpreter.
2. Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.
3. Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.
4. Keflex 500 mg b.i.d. times two weeks with one refill. Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.
CHIEF COMPLAINT: “Refractory Hypertension follow-up”
This is a return visit to the renal clinic for this patient. She is an 85-year-old woman with history of refractory hypertension, cardiac arrhythmia, GI bleed and depression. Her last visit was approximately four months ago. Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she has had for many visits previously. She is not reporting any untoward side effect. She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. She has no orthopnea. Her exercise capacity is about the same. The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. No history of extremity pain.
1. Triamterene 25 mg twice a day by mouth.
2. Norvasc 10 mg daily.
3. Atenolol 50 mg a day.
4. Atacand 32 mg a day.
5. Cardura 4 mg a day.
VITAL SIGNS: Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. THORAX: Revealed lungs that are clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3. I could not hear murmur today. ABDOMEN: Above plane, but nontender. EXTREMITIES: Revealed no edema.
ASSESSMENT: This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.
PLAN: The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us. The patient will continue with her current medication. In the meantime, we will discharge her from our practice. Should there be confusion or difficulty getting in the senior center, we can always see her back in follow-up