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Consultation Note Format

Operative Report Format

SOAP Note Format
 
History and Physical Note Format
 

Consultation Note Sample                                                                               TOP

REASON FOR CONSULTATION:  Globus dysphagia. 

HISTORY OF PRESENT ILLNESS:  This patient is a 60-year-old woman with advanced peripheral vascular disease who underwent femoropopliteal bypass with femoral stenting.  She tolerated the procedure well without complications, but 2 days ago while swallowing a Tums tablet, she felt pain in her throat as the pill was passing down.  Since that time she has had persistent aggravating sensation of a foreign body struck in her upper throat and upper esophagus.  She can swallow liquids and solids fairly well, but she has a long-term history of frequent acid reflux disease and has had intermittent dysphagia to solid food in the past as well.  She denies any melena, hematochezia, or change in her regular bowel habit patterns.  She has been on variety of over-the-counter antacids, which helped her reflux only modestly.  She also has history of Crohn disease, which was diagnosed 15 years ago in New Orleans.  She had been followed by a local gastroenterologist in New Orleans, but has recently changed insurance.  Her disease is apparently well controlled on Asacol 800 mg q.i.d. only.  She is not currently on prednisone.  Other GI review of history includes colon polyps, which were removed by colonoscopy 2-3 years ago.  The patient states that she is due for a followup surveillance colonoscopy.  She reports no significant weight loss and has recently discontinued smoking. 

PAST MEDICAL HISTORY:

1.        Peripheral vascular disease.
2.        Hypertension.
3.        Degenerative joint disease.
4.        Depression.
5.        Gastroesophageal reflux disease.
6.        Hydradenitis.
7.        Questionable history of peptic ulcer disease.
8.        Crohn disease.
9.        Carotid artery disease.

PAST SURGICAL HISTORY:  Hysterectomy, cholecystectomy, femoropopliteal bypass with stenting, and carpal tunnel release.

ALLERGIES:  Tetanus, Accutane, and questionable to prednisone.

CURRENT MEDICATIONS:  Include Procardia, Paxil, Celebrex, Maxzide, heparin subcutaneous q.12h., Tums, and Tylox.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  General:  Reveals an obese, well-oriented woman in no acute distress.  Vital Signs:  Blood pressure 146/86, pulse 88, respirations 18, and afebrile.  HEENT Examination:  Clear.  No scleral icterus is noted.  Neck:  Supple.  No jugular venous distention or masses are detected.  A questionable soft bruit is heard over the left carotid area.  Heart:  Regular rate and rhythm without murmur or gallop.  Lungs:  Exhibit mild upper airway rhonchi.  Abdomen:  Obese, soft, and benign with no masses or organomegaly.  Extremities:  Clear with stapled surgical wounds healing well.

LABORATORY DATA:  The patient’s electrolyte panel was essentially unremarkable.  Hematocrit was 27.8 with a normal MCV.  The white count was normal.

IMPRESSION:

1.        History of globus sensation, which may be secondary to esophageal trauma from her previous calcium pill.  She also has a history of long term reflux symptoms and intermittent dysphagia to solid food.

2.        History of Crohn disease.

3.        History of colon polyps.  The patient is due for surveillance.

RECOMMENDATIONS:  We will perform esophagogastroduodenoscopy tomorrow and if necessary esophageal dilation.  I will hold this patient’s p.m. heparin dose tonight.  We will need to schedule a followup outpatient colonoscopy as well. 

Thank you for having me see this patient.

SURGEON:  Madhu  J. Sudhan, M.D.

ANESTHESIA:  General. 

INDICATION FOR THE PROCEDURE:  The patient is a 50-year-old right-handed woman who was at her work a few hours before admission and she had a fall and sustained a displaced comminuted fracture of the left distal radius.  The patient was advised to undergo surgical fixation of the fracture.  X-rays revealed fracture of the distal radius extending into the wrist joint with dorsal displacement of the distal fragments.

PROCEDURE IN DETAIL:  The patient was taken to the operating room, and she was placed on the operating table in supine position with the left upper extremity extended on the arm board.  Tourniquet was applied to the proximal left arm, and then, the left upper extremity from the tourniquet down to the hand was scrubbed with Hibiclens soap and then rinsed with alcohol and painted with Betadine solution.  Sterile drapes were then applied and the extremity was then exsanguinated and the tourniquet inflated to 200 mmHg. 

We brought in the image intensifier this time for visualization of the fracture.  Fracture was manipulated, and we achieved reduction gently without much difficulty.

A 1-cm transverse incision was made on the radial aspect of the left wrist at the level of the radial styloid.  A blunt dissection was then performed through subcutaneous tissue preventing damage to superficial cutaneous nerve branches.  We exposed the radial cortex of the radial styloid and retractors were placed.  We then inserted, under direct visualization with image intensifier, a smooth guide wire going from distal to proximal.  I closed the fracture site and engaged the ulnar cortex of the proximal fragment of the fracture.  After being satisfied with the position of the pin and reduction of the fracture, we rimmed with a cannulated drill bed and then we inserted an AO 3.5-mm cannulated screw with very good purchase in the bone. 

At this time, we came to the distal aspect of the forearm and a 2-cm longitudinal incision was made.  Bluntly, the soft tissues were dissected down to the cortex of the radius.  Retractors were placed and then under direct visualization with the image intensifier, another guide wire was inserted from proximal to distal going across the fracture site and engaging the most ulnar side of the distal radius without entering the wrist joint and without entering the distal radioulnar joint.  After being satisfied with the position of the second pin we rimmed, and we inserted a second screw of predetermined length, and we got rigid fixation.  With this screw, the fracture was rigidly fixed.  We were able to place the wrist through range of motion without any motion or instability of the fragment.  The last set of radiographs revealed good reduction of the fracture and good position of the orthopedic, however, both in the AP and lateral planes.  Tourniquet was deflated and hemostasis was achieved by compression.  We then closed the skin of both incisions with 4-0 nylon running sutures.  Sterile dressings were applied, followed sterile cast padding and then a long arm cast with the elbow flexed 90 degrees, and the forearm in neutral was applied maintaining the wrist in slight palmar flexion and ulnar deviation.  When the cast was dry, the patient was awakened from anesthesia without any problems and taken to the recovery room in stable condition. 

ESTIMATED BLOOD LOSS:   Minimal. 

COMPLICATIONS:  None.

DRAINS:  None. 

SPECIMEN:  No specimen. 

The procedure was well tolerated by the patient.

SOAP Note Format


SOAP Note Sample

SUBJECTIVE:  The patient is a 76-year-old Caucasian female who came to the emergency room at Harbor Hospital Center with complaints of lower abdominal pain for the past 3 months prior to admission.  The abdominal pain was described as crampy and worsened with eating, and it had worsened over the past 2 days prior to presentation.  The patient had also experienced nausea, but no vomiting.  She denied any change in her bowel habits, denied any hematochezia, melena, fever, chills, sweating, chest pain.  She had also complained of coughing, which was so severe that she had quit smoking 6 weeks ago.  The patient also complained of urinary frequency and dysuria, but no hematuria.  Her appetite had been poor and she reported weight loss of 30 pounds over the past 3 months or so.  While in the emergency room, the patient had received a bolus of 500 cc of normal saline and subsequently developed shortness of breath. 

OBJECTIVE:  General:  The patient is an elderly white female who was found lying in bed receiving oxygen by Venturi mask and, at the time, did not appeared to be in any acute distress.  Vital Signs:  Her blood pressure was 153/85, pulse 89 per minute, respiration 20 per minute, and temperature 96.2.  HEENT:  Revealed normocephalic, atraumatic head and edema and erythema of her eyelids.  Pupils were equal round and reactive to light.  Sclerae were anicteric.  Neck:  Supple and revealed no jugular venous distention, tracheal deviation, or thyromegaly, and no carotid bruit.  Lungs:  On examination had bilateral basilar rales.  Heart:  Revealed a point of maximal impulse at the fifth intercostal space at the midclavicular line, with a regular rate and rhythm with no murmurs or gallops.  Abdomen:  Significant for mild tenderness in the left lower quadrant and right lower quadrant.  There was no hepatomegaly, splenomegaly, or abdominal masses, and bowel sounds were normoactive.  Extremities:  Revealed +1 pitting edema bilaterally in the lower extremities.  Pulses were strong and symmetric. 

ASSESSMENT:

      1.        Acute congestive heart failure secondary to fluid overload, and acute myocardial infarction ruled out.
2.        Abdominal pain, unknown etiology.
3.        Iron deficiency anemia.
4.        Hypertension.
5.        Coronary artery disease.
6.        Hypothyroidism.
7.        Urinary tract infection.

PLAN:  Diet:  Low-salt diet.  Activity:  As tolerated.  The patient is to follow up with primary care physician, Dr. Yeong Oh, in one week.

History and Physical Note Format



History and Physical Note Sample                                                          

PAST MEDICAL HISTORY:  Remarkable for diabetes, hypertension, hyperlipidemia, and ulcerative colitis.

ALLERGIES:  No known drug allergies.

MEDICATIONS:  Synthroid, Premarin, Azulfidine, folic acid, prednisone, and Glynase.

PHYSICAL EXAMINATION:  General:  The patient is a pleasant female in no acute distress.  Neck:  Supple.  Lungs:  Clear.  Heart:  Regular rate and rhythm.  Abdomen:  Soft, benign and nontender.  Extremities:  Showed no edema.  Neurological:  The patient is alert and oriented.

IMPRESSION:  Elevated liver function tests.

RECOMMENDATIONS:  No further workup at this time.  I suspected elevation of liver enzymes are indeed due to fatty liver related to her diabetes.  There is no stricturing, narrowing or abnormalities of the common bile duct.                               TOP