Chart 110 set 3
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School
Holy Family University *
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Course
420
Subject
Medicine
Date
Apr 3, 2024
Type
docx
Pages
6
Uploaded by MateRainCaterpillar31
Chart Readiness – Template for Practice SOAP Notes
1.
Chart #: 110
2.
Chief Complaint(s): Follow up of Incision irrigation and the debridement deep to bone of right ring finger
3.
History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.)
The patient is a 24 y/o male presenting on 11/12/2018 with a follow up of his complaint of his
incision irrigation and the debridement deep to bone of right ring finger. The patient had an open distal failing fracture, Open treatment right ring finger distal failing fracture, Right ring fingernail bed repair. Date of surgery was on 09/25/2018. He is Right hand dominant. He has been in a tip protector. He has been instructed to know heavy lifting with a tip protector to be worn at all times for his work instructions. He claims that it is “about the same.” He admits
that he has no pain, but it is a “bit sensitive” at the end. He admits to wearing his tip protector at all times and admits to “not doing the work yet.” Patient claims to have “skin down there.” He states that the” harder he squeezes it hurts on the palm of his hands.” He states that when he “push his finger,” He feels pain in the “back.”
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Would like a splint to be modified at this time. Instruct to wear it all the time and remove it for bathing purposes. Wear const for next 4 weeks. Discuss it may take time for tingling and numbness to fully return. It was discussed with him that he may have hypersensitivity in his right ring finger for the next few years. Follow up in 1 month for repeat evaluation with 2 views prior to being seen. Patient will call in the interim if he has any concerns or questions.
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
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
Constitutional: Negative chills, fever
MSK: Positive tenderness on the palm of hands.
5.
Past Medical History: (If verbalized during encounter.)
NA
6.
Past Surgical History: (If verbalized during encounter.)
Open treatment right ring finger distal failing fracture, Right ring fingernail bed repair. Date of surgery was on 09/25/2018
7.
Social History: (If verbalized during encounter.)
Employed
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8.
Family History: (If verbalized during encounter.)
NA
9.
Diagnostic Data Discussed:
(Lab work, imaging, EKG, etc. Anything discussed during today’s visit.)
Xray: Two views of the right ring finger demonstrating acuminate right ring finger distal ring fracture that are appropriately reduced. The DIP joint appears concentric. There are NO other
acute or bony abnormalities. There appears to be more callous formation seen in the images today. 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
Right hand: Intact sensation to light touch in the medial ulnar and radial nerve distribution, with the exception of the radial aspect of his right ring finger. It is a bit diminished as he has some dead skin in this area. His swelling is significantly better prior visit. He maintains the 5.0 chromic suture that ties down the nail bed in place. His right ring finger does continue to have a hematoma underneath the nail bed. He struggles to make a full fist as he a stiff at the Dip joint. He has tenderness to palpation. About the entire aspect of his__?__ right ring finger
and into the palm. 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
.
Assessment: 1. Right ring finger distal phalanx fracture
Plan:
1. The splint of the patient is to be modified at this time. He is instructed to wear it all the time and remove it for bathing purposes only. We would like for him to wear it const for the next 4 weeks. It was discussed with the patient that if he feels tingling and numbness he needs to fully return. It was discussed with him that he may have hypersensitivity in his right ring finger for the next few years. Follow up in 1 month for repeat evaluation with 2 views prior to
being seen. Patient will call in the interim if he has any concerns or questions. 12. Please list all orders that should be pended for this visit: Include all lab, diagnostic imaging, medications and referrals.
Follow up in 1 month for a repeat of evaluation with 2 views prior to being seen.
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.)
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