Medical Specialty: SOAP / Chart / Progress Notes

Subjective, Objective, Assessment, Plan. Progress notes, followup notes, etc.

SOAP / Chart / Progress Notes
Acne - SOAP
Acne with folliculitis.
Acquired Hypothyroidism Followup
Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.
Allergic Rhinitis
A 23-year-old white female presents with complaint of allergies.
Anemia & Leukemia Followup
Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.
Aplastic Anemia Followup
Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.
Asperger Disorder
School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.
Atrial Fibrillation - SOAP
Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.
Atrial Flutter - Progress Note
A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.
Bell's Palsy
A 75-year-old female comes in with concerns of having a stroke.
Breast Cancer Followup
A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.
Breast Cancer Followup - 1
Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.
Breast Radiation Therapy Followup
Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.
Bunions and Calluses
A 60-year-old female presents today for care of painful calluses and benign lesions.
CAD - 6-Month Followup
He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.
Carbohydrate Counting
Dietary consultation for carbohydrate counting for type I diabetes.
Cardiology Progress Note
Problem of essential hypertension. Symptoms that suggested intracranial pathology.
Cardiology Progress Note - 1
Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.
Care Conference With Family
Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.
Cataract - Second Opinion
The patient seeks evaluation for a second opinion concerning cataract extraction.
Cataract Extraction Followup
Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.
Cervical Spinal Stenosis
Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.
Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.
Chest Pain & Respiratory Insufficiency
A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.
Chiropractic Progress Note
Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.
Chronic Kidney Disease Followup
Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.
Chronic Kidney Disease Followup - 1
Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.
Chronic Medical Conditions - Followup
Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.
Circumcision Followup
Followup circumcision. The patient had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.
Clostridium Difficile Colitis Followup
Still having diarrhea, decreased appetite.
COPD & Pneumonia - SOAP
Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.
Craniopharyngioma - Postop
Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.
CyberKnife Treatment - Followup
The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.
D&C & Hysteroscopy Followup
D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining. 6. Grade 1+ rectocele.
Dermatitis - SOAP
Hand dermatitis.
Deviated Septum Repair - Followup
The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.
Diabetes Mellitus - SOAP Note - 1
Followup diabetes mellitus, type 1.
Diabetes Mellitus - SOAP Note - 2
Patient today with ongoing issues with diabetic control.
Diabetes Mellitus Followup
Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.
Diabetic Foot Care
An 83-year-old diabetic female presents today stating that she would like diabetic foot care.
Dietary Consult - 1
Elevated cholesterol and is on medication to lower it.
Dietary Consult - 2
The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.
Dietary Consult - 3
The patient is brought in by an assistant with some of his food diary sheets.
Dietary Consult - 4
Counting calorie points, exercising pretty regularly, seems to be doing well
Dietary Consult - Diabetes - 1
Dietary consultation for diabetes during pregnancy.
Dietary Consult - Diabetes - 2
Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.
Dietary Consult - Gestational Diabetes
Dietary consultation for gestational diabetes.
Dietary Consult - Hyperlipidemia
Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome
Dietary Consult - Weight Reduction
Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.
Down's syndrome
A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.
E. Coli UTI - Followup
Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection.
Elevated PSA - Chart Note
Elevated PSA with nocturia and occasional daytime frequency.
Endometrial Cancer Followup
Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.
Erectile Dysfunction - Followup
Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.
Evaluation of Allergies
Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.
Facial Rhytids
Evaluation and recommendations regarding facial rhytids.
Fifth Disease - SOAP
Fifth disease with sinusitis
Followup Screw Fixation
Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.
Foot Lesions
Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.
Foot Pain - SOAP
Patient having foot pain.
Foreskin - Followup
Follow up consultation, second opinion, foreskin.
Fundoplication & Gastrostomy Followup
Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.
Gastric Bypass - Preop Eval
Preop evaluation regarding gastric bypass surgery.
Gen Med Progress Note
The patient states that he feels sick and weak.
Gen Med Progress Note - 1
Sample progress note - Gen Med.
Gen Med Progress Note - 10
Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.
Gen Med Progress Note - 11
5-month recheck on type II diabetes mellitus, as well as hypertension.
Gen Med Progress Note - 12
Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.
Gen Med Progress Note - 13
Sepsis due to urinary tract infection.
Gen Med Progress Note - 2
Sample progress note - Gen Med.
Gen Med Progress Note - 3
Sample progress note - Gen Med.
Gen Med Progress Note - 4
The patient is in complaining of headaches and dizzy spells.
Gen Med Progress Note - 5
A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.
Gen Med Progress Note - 6
A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.
Gen Med Progress Note - 7
Patient with a three-day history of emesis and a four-day history of diarrhea
Gen Med Progress Note - 8
Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.
Gen Med Progress Note - 9
Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.
Gen Med SOAP
Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.
Gen Med SOAP - 1
Sample progress note - Gen Med.
Gen Med SOAP - 10
The patient has NG tube in place for decompression.
Gen Med SOAP - 11
The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure.
Gen Med SOAP - 2
Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.
Gen Med SOAP - 3
General Medicine SOAP note.
Gen Med SOAP - 4
General Medicine SOAP note.
Gen Med SOAP - 5
General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder,
Gen Med SOAP - 6
Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain
Gen Med SOAP - 7
One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well.
Gen Med SOAP - 8
Patient today with multiple issues.
Gen Med SOAP - 9
Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.
Hand Discomfort - Followup
Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.
HIV Followup
Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.
HIV Followup - 1
Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.
Hypertension - Progress Note
Patient with hypertension, syncope, and spinal stenosis - for recheck.
Infected Toenails
This patient has reoccurring ingrown infected toenails.
Ischemic Cardiac Disease - Progress Note
Patient with a history of ischemic cardiac disease and hypercholesterolemia.
Laminectomy & Foraminotomy Followup
Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.
Lap Band Adjustment
Patient status post lap band placement.
Leg Pain - Progress Note
History of right leg pain. Leg pain is no longer present.
Leg Pain & Bone Pain
A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle.
Lobectomy - Followup
The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.
Low Back Pain from Exercise
Patient having low back pain after doing exercise
Lung Biopsy Discussion
Patient is here to discuss possible open lung biopsy.
Lung Cancer Followup
Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax.
Mantle Cell Lymphoma
A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.
Melena - ICU Followup
Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.
Mesothelioma - Chart Note
A woman with end-stage peritoneal mesothelioma with multiple bowel perforations.
MGUS Followup
MGUS. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS.
Multiple Medical Problems
Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.)
Multiple Progress Notes
Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.
Nephrolithiasis - Progress Note
Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.
Neurologic Examination
Neurologic examination sample.
Non-Hodgkin lymphoma Followup
Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy.
Obesity Hypoventilation Syndrome
Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.
Ophthalmology Progress Note - 1
Ophthalmology followup visit note.
Ophthalmology Progress Note - 2
Ophthalmology followup visit note.
ORIF - Followup
Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.
ORIF Facial Fractures - Followup
The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.
Osteoarthritis - Progress Note
Orthopedic progress note for follow up of osteoarthritis, knees.
Overactive Bladder
Overactive bladder with microscopic hematuria.
PAF - 6-Month Followup
Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.
Pain Management Progress Note
Pain management sample progress note.
Physical Therapy - Outpatient Rehab
Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.
Plantar Fasciitis
A 44-year-old, 250-pound male presents with extreme pain in his left heel.
Podiatry - Progress Note
Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.
Poison Ivy - SOAP
Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.
Polycythemia Rubra Vera
Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.
Polycythemia Vera Followup
Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.
Possible Spider Bite
A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.
Postop Parathyroid Exploration & Parathyroidectomy
This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night.
Posttransplant Lymphoproliferative Disorder
Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy.
Progress Note - Iron Deficiency Anemia
Patient developed iron deficiency anemia and had blood in his stool.
Progress Note - Liver Cirrhosis
Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.
Progress Note - Supraglottitis
Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.
Prostate Adenocarcinoma - 1
Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.
Prostate Adenocarcinoma - 2
Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.
Prostate Adenocarcinoma - 3
Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.
Prostate Adenocarcinoma - 4
Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.
Prostate Fossa Irradiation - Followup
The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA.
Prostatitis - Recheck
A 65-year-old man with chronic prostatitis returns for recheck.
Pulmonary - Followup Note
Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.
Pulmonary Medicine Clinic Followup
Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.
Q-Fever Endocarditis
A 16-year-old male with Q-fever endocarditis.
Recheck of ADHD Meds
A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.
Refractory Hypertension - Followup
Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.
Rheumatology Progress Note
Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.
Rotator Cuff Tear
Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.
Sexual Dysfunction - Chart Note
A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis.
Shortness Of Breath - Progress Note
The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.
Sleep Apnea
Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.
Sleep Study Followup
Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.
SOAP - Cholecystitis
She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.
SOAP - Lung Mass
Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation.
SOAP - Numbness & Tingling
Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected.
SOAP - Shortness of Breath
The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist.
SOAP - Substance Abuse
He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.
SOAP - Temporal Mass
MRI demonstrated right contrast-enhancing temporal mass.
Tethered Cord Evaluation
Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.
Three-Week Postpartum Checkup
The patient comes for three-week postpartum checkup, complaining of allergies.
Thrombocytopenia - SOAP Note
Patient with immune thrombocytopenia
Thrombocytosis Followup
Essential thrombocytosis. He underwent a bone marrow biopsy, which showed essential thrombocytosis. His CBC has been very stable.
Total Abdominal Hysterectomy - Followup
Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.
Sore throat - Upper respiratory infection.
Urinary Frequency & Urgency - Followup
Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.
Urinary Retention - Followup
The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.
Uterine Papillary Serous Carcinoma
The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.
Wasp Sting - SOAP
Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.
Weight Loss on Phentermine
Followup on weight loss on phentermine.
Wound Check - Status Post APR
This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy.