SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 5
Description: General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder,
(Medical Transcription Sample Report)
S: The patient is here today with his mom for several complaints. Number one, he has been having issues with his right shoulder. Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. He has been having issues ever since. He is having difficulties raising his arm over his head. He does have some intermittent numbness in his fingers at night. He is not taking any anti-inflammatories or pain relievers. He is also complaining of a sore throat. He did have some exposure to Strep and he has a long history of strep throat. Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation. He is also being seen for ADHD by Dr. B. Adderall and Zoloft. He takes these once a day. He does notice when he does not take his medication. He is doing well in school. He is socializing well. He is maintaining his weight and tolerating the medications. However, he is having issues with anger control. He realizes when he has anger outbursts that it is a problem. His mom is concerned. He actually was willing to go to counseling and was wondering if there was anything available for him at this time.
PAST MEDICAL/SURGICAL/SOCIAL HISTORY: Reviewed and unchanged.
O: VSS. In general, patient is A&Ox3. NAD. Heart: RRR. Lungs: CTA. HEENT: Unremarkable. He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip. Musculoskeletal: Limited in range of motion, active on the right. He stops at about 95 degrees. No muscle weakness. Neurovascularly intact. Negative biceps tenderness. Psych: No suicidal, homicidal ideations. Answering questions appropriately. No hallucinations.
A/P: 1. Right shoulder bursitis. Check x-ray. Rule out fracture, and physical therapy if negative. Continue anti-inflammatories. Suggested joint injections but he denied. 2. Pharyngitis. At moms insistence, we will refer to ENT for possible tonsillectomy. Dr. A name was given. 3. Attention deficit disorder and anger control. Continue present management. Prescriptions x 3 months were given, also names for counseling for his anger issues. He is to RTC in 3 months or as needed.
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