SOAP / Chart / Progress Notes
Sample Name: Bunions and Calluses
Description: A 60-year-old female presents today for care of painful calluses and benign lesions.
(Medical Transcription Sample Report)
S - A 60-year-old female presents today for care of painful calluses and benign lesions.
O - On examination, the patient has bilateral bunions at the first metatarsophalangeal joint. She states that they do not hurt. No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally. The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot. She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter. This is a central plug. She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter. This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.
A - 1. Bilateral bunions.
3. Heloma durum.
4. Painful plantar lesions.
P - Aseptic technique was used. The feet were scrubbed with Hibiclens. Topical anesthetic was applied and the benign lesion on the plantar aspect of the left foot was excised. Blood loss was minimal. Hemostasis was achieved and the wound was dressed with Neosporin ointment and absorbent dressing. The benign lesion on the plantar aspect of the right foot was excised as well. Blood loss was minimal. Hemostasis was achieved and the wound was dressed with Neosporin ointment and absorbent dressing. The heloma durum was shaved bilaterally. The patient tolerated the procedure well. She was informed that she needs orthotics, but she says she cannot afford them. I have recommended to the patient that she stop wearing the small old dress shoes that she is wearing today and obtain a good pair of support athletic-type shoes such as Reebok. Followup is every three months or whenever needed.
Keywords: soap / chart / progress notes, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar,