CS2-Chart 170 Ortho
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University of Phoenix *
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123
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Medicine
Date
Feb 20, 2024
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docx
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4
Uploaded by MajorTigerMaster787
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Chart Readiness – Template for Practice SOAP Notes
1.
Chart #: 170
2.
Chief Complaint(s): Fall, right leg pain
3.
History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.)
The patient is a 36-year-old female with a past medical history of glaucoma, previous rotator cuff tear, and past surgical history of rotator cuff repair, presents in office on 05/06/2019 with right leg pain status post fall while walking down a flight of stairs while visiting Plymouth Rock. She states that her knee “buckled”, and her quadriceps muscle began to cramp which she notes was very painful. The patient was unable to straighten right leg completely. When she attempted to extend her leg, the pain increased. She saw Dr. Bishop prior to arriving to this appointment and was given an immobilizer.
Today, her pain is improving but she reports decreased strength in right quadricep muscles. She denies numbness and tingling in the right foot. The plantar aspect of right foot is uncomfortable but improves with massaging the affected area. The patient has an abrasion on her leg from the immobilizer.
Her social history includes social alcohol consumption. Patient denies using drugs or tobacco. She exercises weekly and always wears her seatbelt.
Patient has no known allergies.
4.
Review of Systems: *
Copy/paste the below ROS into your answer and remove/add as necessary. Please only include pertinent findings.
Constitutional: Negative chills, fever, fatigue
HENT: Negative sore throat, congestion, otalgia
Eyes: Negative blurred vision, eye pain/discharge/redness
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Respiratory: Negative cough, sputum production, dyspnea, wheezing, hemoptysis
CV: Negative chest pain, DOE, orthopnea GI: Negative abd pain, N/V/D, constipation, hematochezia, melena, heartburn
GU: Negative pelvic pain, dysuria, hematuria, frequency, nocturia
MS: Negative back pain, joint pain, myalgia, limited ROM
Integumentary: Negative rash, erythema, pruritus, abrasion, laceration, postoperative site
Neurological: Negative headache, dizziness, paresthesia, speech change
Psychological: Negative anxiety, depression, suicidal/homicidal ideation, insomnia Endocrine: Negative heat/cold intolerance, hair loss, significant weight gain/loss, polyuria, polydipsia
Hematologic/Lymphatic: Negative easy bleeding, ecchymosis, lymphadenopathy
MSK: Positive right leg pain and decreased range of motion. Positive decrease leg strength. Positive discomfort in plantar aspect of the right foot.
Neuro: Negative numbness and tingling
Integumentary: Positive abrasion on right leg.
5.
Past Medical History: (If verbalized during encounter.)
Glaucoma
Previous rotator cuff tear
6.
Past Surgical History: (If verbalized during encounter.)
Rotator cuff repair
7.
Social History: (If verbalized during encounter.)
Social alcohol consumption. She does not use illicit drugs or tobacco. Exercises weekly and always wears her seatbelt.
8.
Family History: (If verbalized during encounter.)
N/A
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9.
Diagnostic Data Discussed:
(Lab work, imaging, EKG, etc. Anything discussed during today’s visit.)
Magnetic Resonance Imaging results.
10. Physical Examination *Copy/paste the below PE into your answer and remove/add as necessary. Please only include pertinent findings.
Constitutional: Well-developed, well-nourished
Head: AT/NC
Neck: Supple, full ROM, no masses, no bruit, no JVD
Eyes: PERRL, EOMI, sclerae anicteric, normal visual fields
ENT: Nose normal, throat clear, no oral lesions, healthy dentition
Cardiovascular: RRR, no murmur or gallop, normal S1 and S2, intact distal pulses
Respiratory: CTAB, normal aeration
Abdomen: Soft, nontender, nondistended, normal bowel sounds, no masses, no organomegaly
Breasts: Bilateral breasts without mass, fullness, or tenderness Back: No tenderness, normal curvature
Extremities: No edema, no muscular or joint tenderness
Lymphatic: No palpable nodes, no adenopathy
Skin: No suspicious lesions identified
Neurological: Speech clear, memory intact, CN II-XII intact, normal coordination, normal gait, 5/5 strength bilaterally, equal sensation bilaterally
Psychiatric: Appropriate, normal judgement
Extremities: No tenderness to palpation of the Right lower extremity.
11. Assessment & Plan
First list diagnosis, then type out the plan. Include any labs ordered. Example: 1.) Breast cancer
Start Arimidex 1mg QD.
Symptoms reviewed/discussed. Ordered: CBC, CMP, CA 15-3, CEA
Follow up in 3 months. 2.) Hypertension
Continue Metoprolol 25mg BID. Encouraged to monitor BP at home three times daily. Bring list of blood pressure readings to next appointment
.
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1.
Right quadriceps tendon tear
-Discussed treatment options. I have recommended surgical intervention and discussed the potential risk. Understands the standard and potential risks of surgery. In the meantime, patient will be partial weight-bearing with crutches by this upcoming Wednesday. 12. Please list all orders that should be pended for this visit: Include all lab, diagnostic N/A 13. Scribed for Dr. _____ by _____, medical scribe, on _____ at _____. I, Dr. _____, have personally reviewed and agree with the information entered by the scribe. (Rewrite this sentence in the answer space, filling in the blanks.)