SUBJECTIVE: The patient presents in followup regarding his left knee. He is postoperative day #11, status post surgical arthroscopy of the left knee for septic arthritis. He is approximately 3 months status post closed reduction and application of a joint spanning external fixator for a left proximal tibia fracture. The patient had been treated for gouty arthritis with prednisone. At the time of his last admission to the hospital, arthrocentesis of the left knee revealed monosodium urate crystals; however, the culture via Gram stain was suggestive of infection. The patient subsequently was demonstrated to have methicillin-resistant Staphylococcus aureus superinfection requiring surgery, which was performed by Dr. John Doe. He has been residing at a rehabilitation facility. He does have a foot drop and has been using a Multi Podus boot to keep the foot in neutral. The patient has made some improvements with physical therapy and has actually been able to flex his knee to 95 degrees. He has had some pain over the past few days. His arthroscopy incisions have healed. The patient is being treated with vancomycin and has a PICC line. He denies any fevers or chills. He has developed some skin irritation over the right heel and has also been using an offloading brace to protect the right heel.
OBJECTIVE: On examination of the left knee, the skin is circumferentially intact. There is no knee effusion. There is no warmth or erythema. There are no local signs of infection. The surgical incisions are healed and sutures were removed. Passive range of motion is from full extension to approximately 90 degrees of flexion. There is pain with flexion past 90 degrees. There is no tenderness to palpation about the proximal tibia. There is no calf pain, swelling or tenderness to palpation. The patient is unable to fully actively dorsiflex the foot against gravity. He is able to plantarflex the foot and toes against gravity. The skin is intact over the heel. There is no calf pain, swelling or tenderness to palpation.
DIAGNOSTIC DATA: Radiographs were not performed today.
ASSESSMENT:
1. Closed left lateral tibial plateau fracture, status post joint spanning external fixation.
2. Septic arthritis, left knee, status post surgical arthroscopy and drainage.
3. Gouty arthritis, left knee.
PLAN: The diagnoses were described in detail to the patient, and the patient’s family. At the present time, his infection is being treated. The patient will continue on the vancomycin. The patient is being followed by the Infectious Disease service. His wounds are healed, and there are no further signs of local infection. The patient may bear weight as tolerated on the left lower extremity. He does not need to use a knee immobilizer or a knee brace. The patient will be fitted for an AFO for his foot drop to assist with ambulation. Physical Therapy will continue to work on active range of motion, active assistive range of motion, passive range of motion, progressive resistance exercises, as well as gait and endurance training. We would like to see him back in 4 weeks’ time for repeat clinical and radiographic evaluation with AP and lateral radiographs of the left knee. If there are any problems prior to the next appointment, he will give me a call.
Orthopedic SOAP Note Transcription Sample Report #2
SUBJECTIVE: The patient presents for followup regarding his left knee. He was seen by Dr. John Doe earlier this month after he sustained an acute injury to his left knee. He was diagnosed with a left medial collateral ligament sprain. He was placed into a Hely Weber brace. The patient has returned to work, and he is on his feet all day long. He continues to have medial sided knee pain with occasional mechanical symptoms such as clicking. The patient denies any instability episodes. The patient denies any other problems.
OBJECTIVE: On examination of the left knee, there is a small knee effusion. There is no warmth or erythema. Sensation is intact to light touch distally. There is no calf pain, swelling or tenderness to palpation. He is able to perform a straight leg raise against gravity. The extensor mechanism is intact. Passive range of motion is from full extension to 125 degrees of knee flexion. Further flexion is limited by patient discomfort. There is tenderness along the medial collateral ligament. There is medial joint line tenderness to palpation, but there is no lateral joint line tenderness to palpation. Lachman test demonstrates a firm endpoint. Posterior drawer test demonstrates a firm endpoint.
ASSESSMENT:
1. Left medial collateral ligament sprain.
2. Question of a left medial meniscus tear.
PLAN: The diagnosis was described in detail to the patient. We will obtain an MRI of the left knee, and the patient will follow up with Dr. John Doe when knee MRI is complete. In the meantime, he is instructed to continue taking anti-inflammatories such as Aleve and to continue using the brace. We have given him his prescription to stay away from work, as we feel he would benefit from a period of rest, icing and elevating the knee. The patient understands the treatment plan as above.
Orthopedic SOAP Note Transcription Sample Report #3
SUBJECTIVE: This (XX)-year-old female, who I have been treating for an ulcer amid her left first metatarsophalangeal joint, enters today with a little bit more pain, much more red. The patient states that she was standing in brown water during the flood from the rainstorm. That is how her foot now has been like this for the last few days.
OBJECTIVE: Ulceration still surrounding the toe. There is breakdown in the center. Surrounding callus is macerated. There is surrounding erythema, edema, pain when palpating. There is increased temperature in the area of the toe.
ASSESSMENT:
1. Cellulitis, local, left first ray.
2. Ulcer, first digit, left foot.
PLAN: Do Gram stain and culture specimen; we will send that down. I am going to send her over for an OrthoWedge and then we are going to send her over to the pharmacy for some Keflex 500 mg one 4 times a day. She can return in 10-14 days.
Orthopedic SOAP Note Transcription Sample Report #4
SUBJECTIVE: The patient returns today. His right shoulder is doing extremely well, status post rotator cuff reconstruction. His operative procedure on the right was performed. He continues to do well.
Recently, he slipped injuring his left shoulder. He was diagnosed with a left massive rotator cuff tear and sent to me for evaluation.
I have evaluated his MRI, which he brings on a disk with him as well as ordered plain x-rays.
OBJECTIVE: Today, on clinical exam, he has 4/5 strength in abduction and external rotation of the left shoulder. He has excellent strength in the right shoulder, status post the repair.
Denies any numbness or tingling distally. No significant AC joint tenderness.
X-ray evaluation was type III acromion.
MRI shows massive rotator cuff tear.
PLAN: Plan would be to do a left shoulder arthroscopic rotator cuff repair and subacromial decompression. I have gone over risks and benefits including infection, bleeding, nerve damage or failure.
Orthopedic SOAP Note Transcription Sample Report #5
SUBJECTIVE: The patient returns to go over his Charcot foot. He had his boot adjusted. He is more comfortable now. He is noticing the bony prominence of the plantar aspect of his foot more and more. He remains noncompliant with weightbearing restrictions and admits that he fully weight bears on it and is just completely unable to not do so. He is also complaining of bilateral knee pain. He had x-rays of these today as well.
OBJECTIVE: He still has some fungal-type plaques on the extensor surface of his leg and foot that is not getting better with over-the-counter antifungals. For this, I am going to have him see a dermatologist. He has no evidence of skin breakdown or callus formation or erythema from boot wear at this point and, I think, it is very well fitting.
X-ray examination demonstrates continued progression and development of a significant rocker-bottom foot deformity. This was once again pointed out to the patient, and the importance of nonweightbearing was once again discussed.
We evaluated his knees that show bilateral knee arthritis, right greater than the left. The patient has had injections for these in the past and is requesting another. So, under aseptic technique and universal protocol, 3 mL of Kenalog and 2 mL of 2% lidocaine plain were injected into the knee joints through an anterior medial portal and the patient tolerated this well.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old male with left Charcot foot deformity. We will keep him in the trial walker boot. Once again, attempted to discuss the importance of nonweightbearing with the patient. For his knee arthritis, we will follow him for this conservatively for now and see him back in four weeks’ time with a new right foot x-ray, and we will have him see Dermatology for evaluation of the skin abnormality.
