SOAP 1

RC – 27 y/o male 

Chief complaint – laceration to left hand

Subjective

RC is a 27 y/o male presenting with laceration to his left hand. Patient admits to cutting his knuckle over the third digit with a piece of tile at work less than six hours ago. He states he applied pressure immediately and bleeding stopped after 30 minutes of direct pressure. His wound was cleaned with soap and water thoroughly, and states he was not going to seek treatment until he noticed he could see his bone. Patient states his last Tetanus was within 5 years. Denies limited movement of fingers with flexion or extension, loss of sensation, weakness, tingling, fever, chills, headaches, dizziness.

Objective 

Vitals 

Temp – 98.4

HR 90 

BP 126/86 

RR 16 

O2 98% RA 

PE

General – alert, in NAD, well developed, well nourished

Skin – warm and dry. No masses, lesions, rashes. 

HEENT – normocephalic, altraumatic, no lesions. No strabismus, exophthalmos or ptosis, sclera white, conjunctiva and cornea clear, PERLA. Pearly white tympanic membrane, cone of light in good position AU, no discharge. Sinuses non tender bilaterally. 

Throat – no erythema or exudates. Uvula midline. 

CV – RRR, S1 S2 normal, no RMG

Respiratory – CTA bilaterally, good air movement, no wheezes, rales, rhonchi 

GI – BS present is all four quadrants. Soft, non distended, non tender. No guarding, rigidity, or masses.

Extremities – 1.5 cm laceration over the third proximal MCP joint of the left hand. Approximately ½ cm deep. Third MCP seen through laceration with no foreign bodies. Dorsal side of hand erythematous and swollen. Capillary refill less than 2 seconds throughout. Radial pulses and sensory function intact bilaterally. Full range of motion with no gross deformities bilaterally. No active bleeding, clubbing or cyanosis.  

Psych – cooperative, good eye contact, clear speech 

Neuro – AOx3, no gross motor or sensory deficits. Normal sensation to simple touch.

Assessment 

RC is a 27 y/o male presenting with laceration over the third proximal MCP of the left hand. 

1. Laceration without foreign body of left hand 

Plan

Closure performed – Prepped and draped in sterile fashion

1% lidocaine, 4-0 nonabsorbable suture; 3 sutures applied

Local wound care discussed. Patient educated to observe for signs of infection, bleeding, and follow up if those symptoms occur 

Suture removal in 10-14 days

 

SOAP 2

AB – 44 y/o male 

Chief complaint – right knee pain x4 days

Subjective 

AB is a 44 year old male presenting with right knee pain x4 days. Patient states he was assembling a bed when he kicked in the metal bed frame with the bottom of his right foot on Thursday. He felt immediate pain in his right knee and has been constant and rated 10/10. Patient states he did not hit his knee directly and the right knee began swelling 3 days later. Admits to limited range of motion and pain while walking and sitting. Patient also states there is more pain during knee extension. Took tylenol for pain with minimal relief. Denies loss of sensation, redness of joints, back pain, headache, fever or chills.

Objective 

Vitals 

Temp – 98.4

HR – 109

BP- 150/95

O2 – 98% room air 

Height 74 in,Weight  205, bmi 26.32

PE

General – alert, in NAD, well developed, well nourished

Skin – warm and dry. No masses, lesions, rashes. 

HEENT – normocephalic, altraumatic, no lesions. No strabismus, exophthalmos or ptosis, sclera white, conjunctiva and cornea clear, PERLA. Pearly white tympanic membrane, cone of light in good position AU, no discharge. Sinuses non tender bilaterally. 

Throat – no erythema or exudates. Uvula midline. 

CV – RRR, S1 S2 normal, no RMG

Respiratory – CTA bilaterally, good air movement, no wheezes, rales, rhonchi 

GI – BS present is all four quadrants. Soft, non distended, non tender. No guarding, rigidity, or masses.

Extremities – Right knee is swollen with effusion with limited range of motion. Pain on resisted extension, strength of extension against resistance is decreased. Tenderness along the medial side of the patella. No muscle atrophy, patellar crepitus, or pain with palpation of the quad tendons. Negative McMurray, anterior drawer and lachman test.  

Psych – cooperative, good eye contact, clear speech 

Neuro – AOx3, no gross motor or sensory deficits. Normal sensation to simple touch

Assessment

44 y/o male presenting with left knee pain x4 days. Must r/o fracture and tendon injury.

1. Possible MCL tear

Plan

Ibuprofen 600 mg PO q 6 hours x10 days

Orthopedic referral 

Sent for outpatient xray 

Return to clinic pending results in 1 week 

Knee immobilizer applied 

Rest and avoid strenuous weight bearing. Keep extremity elevated and apply ice

 

SOAP 3

JM- 52 y/o female

Chief complaint – mouth pain x2 days

Subjective 

JM is a 52 y/o female with no PMH complaining of mouth pain for x2 days. Patient states the pain started when she woke up in the morning and is located above her molars on the inside of her cheek. She states the pain is constant, rated 9/10 and has taken tylenol with minimal relief. The pain is worse on palpation and states this has been interfering with her daily activities. The pain is also felt on her outer cheeks and does not radiate anywhere else. Denies dental pain, sore throat, cough, fever, chills, ear pain, nasal congestion, sputum production, headache or fatigue.   

Objective 

Vitals 

Temp – 98

HR 73 

BP 150/89 

RR 16 

O2 97% RA 

Ht 64, wt 144

PE

General – alert, in NAD, well developed, well nourished

Skin – warm and dry. No masses, lesions, rashes. 

HEENT – normocephalic, altraumatic, no lesions. No strabismus, exophthalmos or ptosis, sclera white, conjunctiva and cornea clear, PERLA. Pearly white tympanic membrane, cone of light in good position AU, no discharge. Sinuses non tender bilaterally. 

Throat – erythema and swelling of stensen duct bilaterally, masses and tender to palpation over parotid glands bilaterally. No erythema or swelling of wharton ducts. No tonsillar or pharyngeal erythema or exudates. Uvula pink, no edema or lesions. Good dentition, no dental caries.

Neck – trachea midline. No lesions, scars, pulsations. Supple, non tender to palpation. No palpable adenopathy.

CV – RRR, S1 S2 normal, no RMG

Respiratory – CTA bilaterally, good air movement, no wheezes, rales, rhonchi 

GI – BS present is all four quadrants. Soft, non distended, non tender. No guarding, rigidity, or masses

Extremities – no clubbing, cyanosis, or edema 

Psych – cooperative, good eye contact, clear speech 

Neuro – AOx3, no gross motor or sensory deficits

Assessment 

JM is a 52 y/o female with no PMH complaining of mouth pain x2 days..

1. Acute sialadenitis 

Plan

Amoxicillin 500 mg 1 tab PO twice a day x10 days

Naproxen 500 mg 1 tab PO q12 hr

Omeprazole 40 mg tab PO once per day

Warm compress, gland massage, hard candy to increase salivary flow  

Patient was advised that if abscess occurs it will need to be drained and in rare cases, surgery may also be needed. She is insisting on mouth x-ray for which I advised her to go to the dentist.