SOAP Note Rotation 2 (Orthopedic Surgery—Elective)
J.D./59M
Subjective:
CC:
Swollen hands and wrists x1 week
HPI:
Pt. is a 59 year old African American male complains of bilateral hand and wrist pain and
swelling that has been occurring for approximately one week. The pain is rated at a
3/10. The pain occurred when carrying groceries from the store to his car. The swelling
and pain start in the morning and symptoms gradually worsen throughout the day. The
pt. has not experienced these symptoms previously. Radiaiton? Aggrevating/alleviating
sx’s? Trauma?
PMH:
Gout, Hepatitis C, Hyperlipidemia, HTN, Asthma
FH:
HTN, denies family history of heart, respiratory, or endocrine disease. Denies family
history of cancer.
SH:
Denies tobacco, alcohol, and illicit drug use. Currently married and lives at home. Not
needed in soap note
Allergies:
No known food or drug allergies.
Meds:
Mobic 15mg, Olanzapine 10mg PO daily, Lisinopril 10mg PO qd, Zocor 20mg PO daily,
Albuterol 2 puffs prn, Ecotrin prn
ROS:
General:
Skin:
Head:
Eyes:
Ears:
Nose:
Mouth:
Tongue:
Teeth:
Gums:
Throat:
Neck:
Cardio:
Resp.:
GI:
Denies weakness, fatigue, malaise, fever, chills, sweats.
Denies lesions, color changes, pruritus, bruising, excessive dryness, texture, hair, nails.
Denies cephalgia, trauma, syncope, lightheadedness
Denies changes in vision, pain, diplopia, photophobia, lacrimation, inflammation,
injection, discharge, jaundice
Denies injury, past disease, decreased hearing, discharge, pain, vertigo, tinnitus.
Denies obstruction, headcolds, discharge, epistaxis, anosmia, abnormal odors, sneezing.
Denies excessive salvation, dryness, pain, bleeding
Denies enlargement, soreness, coating, loss of sense of taste, injury
Denies change in condition, pain, abscess, impaction, dental extraction
Denies bleeding, swelling, ulceration, discoloration
Denies pain, tonsillitis, abscess, difficulty swallowing, nasal discharge
Denies stiffness, pain, welling, pulsations, hoarseness, voice change, aphonia, stridor
Denies dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, palpitation,
irregular heart action, chest pain,edema, coldness of extremities, claudication, night
cramps, ulceration of extremities, gangrene, color changes in extremities
Denies cough, sputum, hemoptysis, wheezing, SOB, pleural pain, injury
Denies appetite, food allergy, nature of diet, selective dyspepsia, dysphagia, beichi
heartburn, sour stomach, nausea, vomiting, hematemesis, jaundice, epigastric distress,
abnormal pain
G/U:
Endocrine:
M/S:
Denies change in voiding volume, dysuria, urgency, frequency, hematuria, pyuria,
incontinence, difficulty starting/stopping, appearance of urine
Denies excessive hunger or thirst , unusual sensitivity to cold/heat, excessive
perspiration, nervousness, fine tremor, striae
Bilateral hand and wrist pain. Denies should, hip, knee, ankle, and back pain. Not
needed in a soap note
Objective:
VS:
General:
Skin:
HEENT:
Wt 195, Ht 74”, BP 176/96, P 59, R 14
Pt. appears stated age, no acute distress, AO x3.
Warm moist with normal turgor, no rashes noted.
Normocephalic, atraumatic, no noted deformities, no conjuctival injection or icterus,
nasal mucosa coral pink without discharge or polyps. Oral mucosa without dryness,
leukoplakia, no ginival or dentition abnormalities
Neck:
No cervical lymphadenopathy, thyroidmegaly, carotid bruits
Lungs:
AP/ Lat ratio 2:1, no deformities, no accessory muscle use, resonant percussion
throughout, clear to auscultation, no adventitous breath sounds noted.
Heart:
S2>S1 at base, RRR, PMI palpated at 5th ICS-MCL, No S3, S4, or murmurs noted
Lymph:
No noted lymphadenopathy in the axillary, inguinal, supraclavicular regions
Peri/Vas:
No marked decrease in pulses bilaterally or proximal to distal
Abdominal:
No visible masses, scars, rashes, ascites, striae. Normoactive bowel sound x4 quadrants,
tympany on percussion. No noted tenderness or guarding. No palpable masses This is a
soap note not an H&P
Mus/Skel:
Upper and lower extremities maintain full ROM both active and passive. No soft tissue
swelling noted. No obvious arthrosis to the IP joint. Negative Tinel’s and Phalen’s test.
This confusing as I do not see an detailed note regarding his wrists. Swelling?
Eccyhmosis? Strength?
Assessment:
Dx:
DDx:
Inflammatory Disease—X-rays completed and showed no bony deformities,
rheumatology panel to be completed to determine etiology of symptoms
Arthritis—no bony deformities seen on x-ray
Gout—history of gout but no crystals seen on x-ray
Plan:
1. Rheumatology paneled ordered to rule out RA and SLE.
2. Continue Mobic
a. 15 mg one tablet daily
b. Serious reactions include GI bleed, GI ulceration, MI, stroke, HTN, CHF, nephrotoxicity,
anemia
c. Pt is currently prescribed Mobic and reports no adverse reactions
3. Patient educated on control of symptoms and to call the clinic if symptoms worsen. You must
delineate the exact symptoms that the patient would know that indicates he is getting worse
and needs to be seen.
4. Follow-up scheduled for 3 weeks in clinic to reevaluate labs and symptoms.
Matt,
-10 points- no signature!!!!!! -5 points incomplete PE -5 points incomplete plan
25/45 JL