Sample of a SOAP note below:
Patient is a 78-year-old man who live insist that use sunblock he walks a lot outdoors and has a very significant and on his arms with a dryness and arms also.
He presented with cough. chest. The symptom started few days ago. It is described as intermittent. Frequency is daily. The complaint is ongoing. Smoking status: Never smoker
Alcohol consumption: Never consumed
Substance abuse: Never consumed
Atenolol (25.00000 – mg), take 1.00 tablet by mouth once a day
Lovastatin (40.00000 – mg), take 1.00 tablet by mouth once a day
Pantoprazole sodium (40.00000 – mg), for 90 days,
Tramadol hcl (50.00000 – mg), take 1.00 tablet by mouth twice a day
Allergies: He has no active known allergies.
Review of History:
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance, Last performed on 10/02/2013.
Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or ct) including arthrography when performed. Colonoscopy, flexible; with biopsy, single or multiple Last performed on 10/20/2010.
Complex uroflowmetry (eg, calibrated electronic equipment), Last recorded on 08/26/2010.
Voiding pressure studies (vp); bladder voiding pressure, any technique. Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging, Last recorded on 08/26/2010.
Cystourethroscopy (separate procedure), Last performed on 08/03/2017.
Biopsy, prostate; needle or punch, single or multiple, Last recorded on 07/02/2014.
Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level.
Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (list separately in addition to code for primary procedure).
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification).
Reviewed the following past medical:
Essential (primary) hypertension.
Gastro-esophageal reflux disease without esophagitis.
Benign prostatic hyperplasia without lower urinary tract symptoms. Barrett’s esophagus without dysplasia.
Elevated prostate specific antigen [psa].
Benign prostatic hyperplasia with lower urinary tract symptoms.
Ventral hernia without obstruction or gangrene.
He is married, never smoker, has never consumed alcohol, is a current every day consumer of coffee or tea, is not a substance abuser, has a Dairy Free diet, follows a balanced diet, has sufficient rest or recreation, does not have a risky sexual behavior, does not have disabilities, does not have family stress, does not have job stress, does not do physical exercise,has living arrangements: Private Residence with Family.
Family History: His family presents the following diseases: his Mother has Heart disease (high blood pressure), his Father has Heart disease (heart).
Eyes: The patient denied change in vision, eye pain, redness, discharge.
Ears, Nose, Mouth, Throat (ENT): The patient denied loss hearing, congestion, sinus pain, change in hearing, ringing in ears (tinnitus), frequent nose bleeds (epistaxi), sore throat, hoarseness, ear pain, pain in throat.
Respiratory: The patient complained of cough, but denied wheezing, hemoptysis, phlegm.
Cardiovascular: The patient denied chest pain, palpitations, dyspnea, orthopnea, shortness of breath, hypertension.
Gastrointestinal: The patient denied acidity, gastritis, flatulence, hiccups, abdominal pain, difficulty swallowing(solids vs liquids), bloating, nausea, diarrhea, constipation, bright red blood per rectum (BRBPR,hematochezia), vomiting_, change in bowel habits, hemorrhoids. GU/Gyne/0B: The patient denied dysuria, hematuria, incontinence, pain with urination, cloudy urine, rectal discomfort.
Musculoskeletal: The patient complained of pain. Left Hip Pain, but denied wound, swelling (edema), tenderness, weakness, areas of numbness. Neurological: The patient denied dizziness, faints, headache, numbness, limb weakness, tremor, memory loss.
Psychiatric: The patient denied depression, anxiety, insomnia, suicidal thoughts.
Endocrine: The patient denied – diabetes mellitus, hair loss, heat or cold intolerance, change in facial or body hair, cf\ange in weight. lnteg.urnentary (skin and/or breast): The patient denied itching, change in moles, dry skin, ecchymosis, onychomycosis, lesion, abscess, rash. Hematologic/Lymphatic: The patient denied anemia, easy bruising, tender or palpable lymph nodes.
Allergic/Immunologic: The patient denied other reactions, sneezing, runny nose, post nasal drip.
Constitutional: The patient denied fever, weight loss, weight gain, night sweats, fatigue/malaise/lethargy.
Vital Signs: Weight: 176 lb O oz. Height: 5 ft 8 in.
Pulse: 64 bpm. Pulse: Normal, interpretation: Normal
Blood Pressure: 140/70 mmHg. Location: Left Arm. Position: Sitting. Temperature: 97.6 degrees F. BMI: 26.8 kg/m2. Respiratory rate: 16 bpm.
PE: Constitutional: Overall: Alert, cooperative.in no distress.appears stated age. Development: well developed. Nourishment: well nourished. Eyes: Eye: Conjunctivae and sclerae are clear without icterus.Pupils are reactive and equal..
Ears, Nose, Mouth, Throat (ENT}: Head: Normocephalic, without obvious abnormality,atraumatic .. Ears: Normal external ear canals, both ears .. Nose: mucosa normal no drainage.bleeding .. Throat: Lips mucosa , and tongue normal; teeth and gums normal. Neck: Supple,Symmetrical,trachea midline,no adenopathy,no carotid bruit or JVD. Thyroid gland: normal. Mouth: Lips mucosa , and tongue normal; teeth and gums normal. Cardiovascular: Pulse: regular. Blood pressure: normal. Auscultation: murmur. I/VI SEM.
Respiratory: Chest and Lungs: Clear to ascultation bilaterally, respiration unlabored,no wheezing, rales or crackles ..
Gastrointestinal: Abdomen: hernia. Huge midline hernia Stable. Rectal: deferred. GU/Gyne/OB: Genitalia: deferred.
Musculoskeletal: Hip: pain. Left Hip pain in scale 1 -10 reports 7. Upper extremities: normal atraumatic, no cyanosis or edema. Lower extremities: normal atraumatic, no cyanosis or edema.
lntegumentary (skin and/or breast): Skin: Skin color,texture,turgor normal.no rashes,or lesions .. Nails: normal.
Neurological: Cranial nerves: Cranial Nerves II-XII appears intact. Motor: normal. Coordination and Gait: Alert,Oriented. Reflexes: Strength normal. Sensory: Alert.Oriented,
Psychiatric: Orientation to time, place and person: normal. Recent and remote memory: normal. Mood and affect: No distress,mood looks normal,no agitation,no hallucinations.
Hematologic/Lymphatic: Groin: normal. Other: Cervical, supraclavicular and axillary nodes normal.
Chest / Breast: Breasts: normal.
Essential (primary) hypertension.
Body mass index (bmi) 26.0-26.9, adult.
Follow up on 1 month
Kenalog 40 mg IM,
Zithromax Z Pack
Cholesterol diet – deeply colored fruits and vegetables, fiber rich grain products, fat-free products, 1 percent and low fat milk products, lean meats and poultry without skin, fatty fish, nuts, seeds, an legumes(dried beans or peas), and unsaturated vegetable oils ..
Patient Education: She received verbal educational instructions for All the questions was answered and understood, breast self exam, Call or Return if Symptoms worsen or persist, Depression Screening Performed today, Discussed Bowel and Bladder Control, Fall precautions and Accident prevention, I Discussed all treatment options with the patient, Reviewed all Current Medications, seat belt, Skin protection, stress