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Clinical Chart Soap Note Example

Clinical Chart Soap Note Example

Patient Information:

Initials, Age, Sex, Race,

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S:

Chief Complaint: left hip pain

 

HPI:

Mrs L, a 66 year old Caucasian female present to the clinic with complaints of left hip pain which she first noticed 3 weeks ago. She reports experiencing pain more frequently now, it is almost constant with walking or standing for a long period of time. It is a throbbing pain with does not radiate. The pain is aggravated by walking, bending, standing, squatting and relief is noted with rest. She has taken Ibuprofen 800 mg intermittently for the pain, and states at worst the pain rated as 8/10, at best 0/10 when at rest.

Current Medications:

Ibuprofen 200-800 PRN hip pain

Allergies: None stated

PMHx:

No chronic illness. Chicken pox as a child. No hx previous fractures.

All vaccines up to date

PSHX: Hysterectomy 20 years ago, Cholecystectomy 20 years ago

Health screening:

Last mammogram 5 years ago, colonoscopy WNL, no history of DEXA

Soc Hx:

Single, Retired x 4 years, previous office management, non-smoker, occasionally has a glass of wine with dinner, no illicit drugs, walks 1 mile a day.

Fam Hx:

Parents are deceased, siblings in good health.

ROS:

General: denies headache, vision changes, night sweats, fever

CV: No chest pain, palpitations

Respiratory: No SOB, no cough

Musculoskeletal: Reports pain with standing, walking, squatting, no back pain,

Neuro: No numbness, tingling, or weakness noted in extremities

O:

Physical Exam:

BP: 123/84; HR 80; RR 20; T: 98.5; Hgt: 5’2″; Wgt: 120 lbs; BMI: 20 (weight loss of 7 lbs from last year)

General: No acute distress

HEENT: Head normocephalic without evidence of masses or trauma.

PERRLA, EOMs intact, non-injected. Ear canal without redness irritation, TMs clear, pearly, bony landmarks visible, no discharge, no pain noted. Neck negative for masses, no thyromegaly. No JVD distention.

Skin: intact. No bruising noted.

CV: S1/S2, RRR, no murmurs, no rubs

Lungs: CTA bilaterally.

Abdomen: Soft, non-tender, non-distended, BS present x 4, no organomegaly, no bruits

Musculoskeletal: No pain to palpation of left or right hip ; Right leg: full active and passive ROM Left leg: Decreased active and passive ROM with stiffness and report of discomfort. Antalgic gait noted with rise from seated position, to standing, and initiation of ambulation

Neuro: Sensation intact bilateral upper and lower extremities, bilateral UE/LE strength 5/5

Psych: PHQ 9 score 5

Diagnostic or Lab results: None Available

A:

Primary Diagnosis: Osteoarthritis (M16.12):

Secondary Diagnosis: Health maintenance, Gait Disturbance (ICD-10 R26.89):

Differential Diagnoses:

Hip fracture (stress fracture) (ICD-10 M84.352):

Osteoporosis (M81.0):

P:

Diagnostics:

25-hydoxyvitamin D, calcium level

X-ray of the left hip

DEXA

Medications:

· Ibuprofen 200 mg tablet (treatment of OA)

Sig: Take 2 tablets three times daily, Disp: 120 Refill: 3

· Tramadol 25 mg tablet

Sig: take one tablet every 6 hours as needed for severe pain. Disp: 20 Refill: 0

Education:

Discussed OA diagnosis and will screen for osteoporosis with DEXA

Reviewed medications

Recommend water aerobic/hydrotherapy

Exercises should stress range of motion and stretching such as yoga or tai chi

Hot and cold therapy as tolerated. Heat applied prior to exercise to reduce aches, cold following exercise to reduce swelling and relieve pain. Use heat no longer than 15 minutes at a time and cold therapy for no longer than 20 minutes at a time to prevent thermal injury

Discussed fall prevention. Recommend removing throw rugs from the home due to gait.

Physical therapy referral to assist with gait

PHQ 9 score 5: discussed to call office if experiences increased signs of depression

mammogram scheduled

Referrals: GI for colonoscopy, physical therapy

Follow up: return to office in 2 weeks to evaluate pain level and review diagnostics results.

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