SOAP note #1

Subjective:

39-year-old female with PMH of HTN. She presented to the ED with acute onset abdominal pain yesterday that occurred after dinner. Pain is located in the bilateral upper quadrants, worse on the right than the left and non radiating, constant, and sharp 5-8/10. No aggravating or alleviating factors. She denied nausea, vomiting, fevers, chills, changes in bowel habits, chest pain, shortness of breath. This has never happened before. She denies past surgical history. She is a non smoker and a non drinker.

Objective:

Vitals:

T 98.3 oral

HR: 97 beats per minute, regular

RR: 18, unlabored

BP: 128/82

O2: 96% RA

PE:

heart: regular rate and rhythm, S1 and S2 present, no murmurs. Lungs: clear to auscultation bilaterally. Abdomen: tender in the bilateral upper quadrants, soft,  BS +  in all 4 quadrants, + Murphy sign.

Labs:

CBC: WBC|RBC|Hb|Hct|Platelets  15.58| 4.37| 13| 38.7| 405

BMP: Na|K|Cl|CO2|BUN|Cr|Ca      136| 4.6| 99| 23| 16| 0.49| 9.4

Hepatic: ALP 130 ALT 60 AST 31 total bilirubin: 0.3

Imaging:

CT: multiple gallstones and potential widened common bile duct

US: shows stones, gallbladder is distended, normal common bile duct diameter

Assessment:

39-year-old female with symptoms and imaging consistent with cholecystitis

Plan:

-admission: IV fluids and IV Zosyn, NPO

-laparoscopic cholecystectomy today

SOAP note #2

Subjective:

63-year old female with past surgical history of total abdominal hysterectomy and bilateral salpingo oophorectomy (9/2006 at QHC) and exploratory laparotomy, lysis of adhesions, small bowel resection and repair of large and small hernias (6/2012 at QHC) presents to the general surgery clinic today for the evaluation of an abdominal hernia. The patient reported an abdominal bulge present for a number of years. Patients denied abdominal pain, nausea, vomiting, chest pain, shortness of breath, changes in urination. Patient also complains of rectal pain with defecation and intermittent urges to have bowel movements without actually emptying the bowel. Patient denies melena and bright red blood per rectum. Patient denies ever having a colonoscopy. Patient denies past medical history.

Objective:

Vitals:

T: 97.9 F orally

HR: 86, regular

RR: 18, unlabored

BP: 136/64

O2: 99% RA

PE: patient is in no acute distress, lungs are clear to auscultation bilaterally, heart rate is regular, S1 and S2 present, abdominal exam patient is obese, soft, nontender, and non distended BS + in all 4 quadrants, non strangulated left ventral hernia is palpated, it is non tender.

Assessment:

 63-year-old female with large ventral hernia and rectal pain

Plan:

-refer to proctology clinic for rectal pain and colonoscopy

-BMP and CT abdomen pelvis ordered for ventral hernia assessment

-return to the clinic in 3 months after the colonoscopy results.

SOAP note # 3

Subjective: 34-year-old female with past medical history of stage IIa right breast invasive cancer ER/PR+, HER2 negative, status post right breast modified radical mastectomy in 7/2019, status post benign core biopsy 11/2019, status post radiation and chemotherapy on tamoxifen, annual left mammogram done 6/2021 was BIRAD 1 presented to the breast clinic today. Patient was recently admitted to the medicine service at QHC for right upper extremity cellulitis, presented today for follow up. She has no new complaints today. She states her redness resolved, swelling of the right upper extremity is improving, however she still has pain in the axilla and pain with movement. She denies fever, chest pain, shortness of breath.

Objective:

Vitals:

T: 98.9 F orally

HR: 62, regular

RR: 16, unlabored

BP: 144/78, left arm

O2: 99% RA

PE: in no acute distress, lungs clear to auscultation bilaterally, heart regular rate and rhythm S1 and S2 heard. Right upper extremity swelling noted 33cm circumference on the right, left 30 cm. No erythema noted. Tenderness noted in the axillary region. Patient has a well healed mastectomy scar with dense tissue on the right, with radiation changes, excess tissue in the midaxillary region.

Assessment:

34-year-old female with stage IIa right breast cancer status post right modified radical mastectomy, status post left benign core biopsy, with resolved cellulitis of the right upper extremity with some swelling and edema remaining in the right upper extremity vs lymphedema of the right upper extremity. Patient has dense tissue around the mastectomy site.

Plan:

• Right upper extremity elevation
• Referral to OT for right upper extremity exercises
• Right sided breast US ordered to evaluate for dense tissue around the mastectomy site
• Return to clinic 3 weeks after completed US

SOAP note #4:

Subjective: 35-year-old female with no PMH presented to the proctology clinic earlier this month with rectal bleeding since December 2020. Rectal bleeding occurred when she was straining to have a bowel movement. Since DEcember she has additionally developed hemorrhoids that would pop out of the anus when she would strain. These hemorrhoids caused her pain and discomfort. After having a bowel movement she was able to replace the hemorrhoids in her rectum. She was taking fiber supplements which provided some relief to her constipation. Patient denies nausea, vomiting, fever, chest pain, shortness of breath. She has a past surgical history of breast implants and is a non-smoker.

Objective:

Vitals:

T: 98.4 F orally

HR: 94 regular

RR: 12 unlabored

BP: 122/74

O2: 100% RA

PE: in no acute distress, heart S1 and S2 regular rate and rhythm, lungs clear to auscultation bilaterally. abdomen is soft and non distended and nontender, BS + in all 4 quadrants, rectal exam + internal polyp, external skin tag. No fissures noted.

Assessment:

 35-year-old female with anal polyp and hemorrhoid, causing pain and discomfort with bowel movements. The skin tag does not bother the patient.

Plan:

• Exam under anesthesia today with excision of polyp and possible hemorrhoidectomy
• Plan for discharge home after the procedure, return to clinic in 2 weeks

Soap note #5

Subjective:

D.S. is a 19-year old male with no past medical history. He was seen in the ED on 2/25/21 for bilateral groin pain and was referred to the general surgery clinic to rule out a hernia. Patient has bilateral groin pain worse on the right than the left for the past 4-5 months. The pain is constant, feels heavy and 3-5/10. It does not radiate. No aggravating factors. Patient takes ibuprofen 400 mg every 6 hours to help with pain.  Patient works in construction and has to lift heavy objects. Patient denied difficulty urinating, testicular swelling, fevers, bulge/mass in the groin, nausea, vomiting, constipation, diarrhea, shortness of breath, chest pain, palpitations. 

Objective:

Vitals:

T: 97.7F oral

HR: 65 regular

RR: 18 unlabored

BP: 118/80

O2: 100% room air

Height: 5’7”

Weight: 63 kg

BMI: 21.8

PE: in no acute distress. Heart regular rate and rhythm S1 and S2 auscultated. Lungs clear to auscultation bilaterally. Abdomen soft and nontender. Bowel sounds present in all 4 quadrants. reducible right inguinal hernia noted on valsalva. No left inguinal hernia noted.

Labs:

CBC: WBC|RBC|Hb|Hct|Platelets 7.4| 5.08| 14.2| 43.5| 183

Type and screen: B positive

Covid: negative

Assessment:

19-year-old male with bilateral groin pain for 4-5 months, reducible right inguinal hernia noted on exam. No left inguinal hernia noted

Plan:

–right inguinal hernia repair with mesh scheduled for tomorrow

-NPO after midnight

-education and teach back provided regarding no heavy lifting 4-6 weeks after surgery

Soap note #6

Subjective:

J.S. is a 78-year-old male with past medical history of hyperlipidemia, chronic venous stasis ulcers (bilaterally), BPH, and hypertension presented to vascular surgery clinic for weekly unna boot change. He is doing well with no new complaints. Denied fever, chills, bleeding, drainage or leg pain.

Objective:

Vitals: none taken for this visit

PE:

 Lower left extremity shows stasis skin changes, with hyperpigmentation, dry skin. Medial ulcers measure 11x7cm, 3×5 cm, and 4x3cm. The left anterior shin ulcers measure 2×1 cm, 3×2 cm, 3×1 cm, ulcers are all pink and contain granulation tissue. There are no signs of infection or hyperkeratotic skin

Lower right extremity shows stasis skin changers, hyperpigmentation, hyperkeratotic skin. There is a single lateral ulcer measuring 3×4.5 cm containing pink granulation tissue, with no signs of infection.

No calf tenderness bilaterally.

Assessment

78-year-old male with bilateral venous stasis ulcers

Plan

-bilateral unna boot applied today

-continue with leg elevation and ambulation

-return to clinic in one week for unna boot reapplication

Soap note #7

Subjective

J.N is a 40-year-old male with a 10 pack year smoking history, no other past medical history who presented to the ED with right sided chest pain. Chest pain began 4 days ago. Pain is sharp, non radiating and 8/10. Pain is worse with deep breaths and is associated with a significant cough which began 4 days ago. Patient denies shortness of breath, fever, chills, weight loss, night sweats, recent travel, and sick contacts. This has never happened before. 

Objective:

Vitals:

T: 98.4 oral

HR: 79 regular

RR: 22 labored

BP 118/88

O2: 100% 6L O2 nasal cannula

PE: not in acute distress, normal texture and turgor of skin, neck is symmetric with midline trachea, heart regular rate and rhythm S1 and S2 noted. Unlabored breathing on nasal cannula, equal chest rise bilaterally, decreased lung sounds on the right. Abdomen is soft, nontender and non distended. Bowel sounds present in all 4 quadrants.

Labs:

CBC: WBC|Hb|Hct|Platelets 12.09| 15.4| 48.3| 298

BMP: Na|K|Cl|CO2|BUN|Cr|Ca 141| 4.6| 99| 24| 7| 1.11| 9.8

PT: 13 INR: 1.1 APTT 36.1

Imaging:

CXR: large lucency of the right upper midlung suggestive of large right pneumothorax

Assessment

40-year-old male smoker with 4 days of chest pain, CXR shows large right pneumothorax

Plan

-place pigtail catheter and attach chest tube to wall suction in the right thorax

– admission to surgery floor

-daily chest x rays

-regular diet

-DVT prophylaxis with 40 mg SQ lovenox

Soap note #8

Subjective

RM is a 63-year-old female with PMH of DM2, HTN, bilateral cataract surgery in 2019, fibroids, varicose veins of the LLE, is currently admitted to medicine to rule out temporal arteritis. Patient came to the ED with one day of left sided floaters in the eye, left sided unilateral throbbing headache. She denies jaw claudication, blindness, other vision changes, fatigue, fever, chills, nausea, vomiting.

Objective:

Vitals:

T: 98.4 oral

HR: 74 regular

RR: 18 unlabored

BP: 130/80

O2: 98% room air

PE: in no acute distress, PERRL, vision grossly intact, left temporal tenderness. S1 and S2 auscultated RRR. lungs clear to auscultation bilaterally

Labs:

CBC: WBC|RBC|Hb|Hct|Platelets 7.48| 4.17| 11.8| 36.5| 257

BMP: Na|K|Cl|CO2|BUN|Cr|Ca 139|4.5| 105| 22| 17| 0.74| 9

ESR: 63

CRP: 10

Imaging:

Head CT without contrast: no evidence of acute intracranial abnormality

Chest XR: no acute findings

CT angio head with contrast: no intracranial stenosis or occlusion

CT angio neck with contrast: no carotid or vertebral artery stenosis

Assessment:

63-year-old female with PMH of DM2, HTN, bilateral cataract surgery, fibroids, varicose veins of the LLE complaining of left sided vision floaters and a left sided headache. Physical exam reveals left temporal tenderness. ESR and CRP slightly elevated. Imaging is within normal limits. Consulted to rule out temporal arteritis.  

Plan:

-continue steroids

– biopsy temporal artery

– vascular surgery will follow