SOAP / Chart / Progress Notes
Sample Name: Tethered Cord Evaluation
Description: Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.
(Medical Transcription Sample Report)
REASON FOR VISIT: The patient referred by Dr. X for evaluation of her possible tethered cord.
HISTORY OF PRESENT ILLNESS: Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.
Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1.
MEDICATIONS: Singulair for occasional asthma.
FINDINGS: She is awake, alert, and oriented x 3. Pupils equal and reactive. EOMs are full. Motor is 5 out of 5. She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus. There is no evidence of clonus. There is diminished sensation from L4 to S1, having proprioception.
Keywords: soap / chart / progress notes, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele,