SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 9
Description: Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.
(Medical Transcription Sample Report)
SUBJECTIVE: This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently, but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs. It feels likes it is in his chest. He has been taking Allegra-D intermittently, but he is almost out and he needs a refill. The second problem, his foot continues to breakout. It seems like it was getting a lot better and now it is bad again. He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream. I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence. He works in the flint and it is really hot where he works and it has been quite humid lately. The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger. He is interested in getting that frozen today. Apparently, he tells me I froze a previous wart on him in the past and it went away. Next, he is interested in getting some blood test done. He specifically mentions the blood test for his prostate, which I informed him is called the PSA. He is 50 years old now. He will also be getting his cholesterol checked again because he has a history of high cholesterol. He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking. He says it is difficult to quit. He tells me he did quit chewing tobacco. I told him to keep trying to quit smoking.
REVIEW OF SYSTEMS: General: With this illness he has had no problems with fever. HEENT: Some runny nose, more runny nose than congestion. Respiratory: Denies shortness of breath. Skin: He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today. At times it is itchy.
OBJECTIVE: His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16. General exam: The patient is nontoxic and in no acute distress. Ears: Tympanic membranes pearly gray bilaterally. Mouth: No erythema, ulcers, vesicles, or exudate noted. Neck is supple. No lymphadenopathy. Lungs: Clear to auscultation. No rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm without murmur. Extremities: No edema, cyanosis, or clubbing. Skin exam: I checked out the bottom of his right foot. He has peeling skin visible consistent with tinea pedis. On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart. The size of this wart is approximately 3 mm in diameter.
1. Upper respiratory tract infection, persistent.
2. Tinea pedis.
3. Wart on the finger.
5. Tobacco abuse.
PLAN: The patient is getting a refill on Allegra-D. I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day. I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work. His wart has been present for some time now and he would like to get it frozen. I offered him the liquid nitrogen treatment and he did agree to it. I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart. He tolerated the procedure very well. I froze it once and I allowed for a 3 mm freeze zone. I gave him verbal wound care instructions after the procedure. Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test. Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days.
Keywords: soap / chart / progress notes, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart,