Samples of Medical Documents

Back to List of Samples / Back to Free Stuff


S: The patient presents for a physical. His main problem has been some pains in the neck, elbows and lower back. The back pain has been present for just a few days and is slightly worse with movement. He has had pains in his elbows for approximately four months. It is relatively constant, no extreme. It does tend to hurt when he supinates his forearm fully. He has also had some mild pain in the back. At one time, he was thought to possibly have cervical disc disease; however, a CT scan of the cervical spine was unremarkable. He has no other significant history. Social: He is a nonsmoker. Family history: His father does have some mild arthritis and also has hypertension and heart disease.

O: HEENT: Tympanic membranes are clear bilaterally. Nose and throat are clear. Neck is supple without lymphadenopathy or bruits. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft, flat, nontender, and nondistended. Bowel sound are active. He has some minimal tenderness in the right lower quadrant. Back: There is trigger-point tenderness. Lower extremities are normal to exam. He has negative straight leg raising in the supine position.

Laboratory studies were within normal limits, with the exception of his cholesterol which was 236 and his triglycerides which were 320. He is not watching his diet at all.

A: Strain of the lower back. I think this may well be due to his work as a clerk. He spends a lot of time at a computer keyboard.

P: He is to take the strain off of his elbows and lower back. I also gave him an instruction sheet on a low-cholesterol diet. He will try to follow this for six months, and we will recheck his cholesterol then. He asked if I would recommend taking niacin. I told him that it might have some beneficial effect and was probably relatively safe for him to take.

Return to top

CHIEF COMPLAINT: The patient is a 46-year-old Caucasian male admitted to detox on _____________ with the patient stating, "I'm at the end of my rope."

HISTORY OF PRESENT ILLNESS: He admitted to using fentanyl patches for six months as well as taking 20 to 30 Lorcet daily for at least three months, smoking 1 pack of cigarettes daily, and drinking 3 beers and/or 3 to 5 mixed drinks per day. He had been treated eight years ago for anxiety and depression and was treated also prior to admission with Remeron but had not taken it since__________________. He had three prior detoxes previously.

REVIEW OF SYSTEMS: There was no history of hepatitis or sexually-transmitted diseases. Allegedly, he had a negative HIV test in the last few years but was not sure of the date. He denied any history of cardiovascular disease or diabetes. He complained of nausea and vomiting. His weight had been stable in the preceding six months. He admitted that he had been taking apart the fentanyl patches, which had been prescribed for his back pain, and had been sniffing the active ingredient off of the patch.

SOCIAL HISTORY: He had no current legal issues. He was married and living with his wife but questioned whether or not she was really supportive of his problems. He was a full-time employed ______.

FAMILY HISTORY: He denied any family history of addiction.

PAST MEDICAL HISTORY: He used an albuterol inhaler for a diagnosis of "asthma." He had had a laminectomy in ____ and three surgeries on his left ankle in ____, ____, and ____.

PHYSICAL EXAMINATION: General: He appeared as a heavy-set, weepy male smelling of alcohol. He blew a 0.6 on the Breathalyzer. Vital Signs: Height was 6 feet. Weight was 265 pounds. Temperature was 97.9?F. Blood pressure was 128/78. Pulse was 108. Respirations were 18. HEENT: Head was atraumatic. There was no icterus or cyanosis. Neck: Not unusual. Lungs: Slightly decreased breath sounds. Heart: Sounds and rhythm normal. Abdomen: Very obese, nontender, no masses, and no liver, spleen or kidneys palpable. Extremities: He was wearing a bandage on his left hand due to a recent tendon repair over the laceration.

X-RAY and LABORATORY FINDINGS: Liver enzymes were normal. Albumin was 5.3. MCV was 97, the remainder of his CBC was normal. RPR was nonreactive.

HOSPITAL COURSE: Treatment was with sublingual and transdermal clonidine. He also required albuterol for some bronchospasm, Ultram for withdrawal cramps, Phenergan for nausea, and Imodium for diarrhea. He attended group and individual counseling sessions and appeared to participate well.


DISCHARGE DIET, ACTIVITY, and FOLLOW-UP INSTRUCTIONS: He is discharged today to follow up with outpatient therapy on _______ at ____ p.m.


1. Acute and chronic addiction to opiates, alcohol and nicotine.
2. Chronic obstructive pulmonary disease, mild.
3. Lumbar discopathy, status post laminectomy.

Return to top
TYPICAL SOAP NOTE (subjective, objective, assessment and plan)

S: This is a 78-year-old white female with multiple complaints. She has a history of chronic sinusitis, esophagitis, a fibromyalgia-type syndrome, and depression. She complains today of continued problems with pain in the left cheek and preauricular area, especially in the morning. The pain gets very intense at times. She also has a great deal of postnasal drainage which gives her a sour feeling in her stomach. She also complains of some dizzy spells over the last few months, usually when she is working around the house. These are associated with some sweating and nausea. She has not ever had any loss of consciousness. She also complains of recurrent problems with constipation, especially over the last three months. She has been using Correctol. This tends to give her runny stools for a day and then she has constipation again the next day. She has tried taking Colace. This was not helpful.

O: General: She is a well-nourished, well-developed, elderly white female in no acute distress. She appears somewhat sad and tearful. HEENT: Tympanic membranes were clear bilaterally. Nose had some pale mucosa, otherwise clear. She had tenderness along the left maxillary and left preauricular areas, and some mild temporomandibular joint tenderness. Throat was clear. Neck was supple. Lungs: Clear to auscultation. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft and diffusely tender to a mild degree. Bowel sounds were active.

A: 1. Depression.
2. Recurrent sinus pain.
3. Constipation.
4. Esophagitis.

P: 1. She has been off Zoloft for a while, so we will have her resume that. There is no record in the chart of her ever having an adverse reaction to it. 2. Beconase AQ 2 puffs b.i.d.
3. For her constipation, I recommended using Metamucil or some other type of similar fiber, and increasing her fluid intake. She is going to make an appointment with Dr. Suess at his next opening, so that he can follow up on how she is doing with these changes. If she continues to have the sinus pain, we may need to refer her to an otolaryngologist.

Return to top

RE: Prince Charming

Dear Dr. Doolittle:

I am sending Prince Charming to you in regards to some leukopenia and thrombocytopenia. He was a previous patient of The Wicked Witch and evidently had some low platelets and white counts in the past. In February, he had a white count of 4100 with essentially a normal differential. His platelet count was 130,000.

We repeated his complete blood count recently. He continues to have no anemia, but his white count is now 2800 and platelet count is 109,000. Antinuclear antibody was negative. His blood chemistry profile did show a mildly low globulin at 1.7. Uric acid was slightly elevated at 8.7. Bilirubin was at 2. His retic count was 3 with an absolute reticulocyte count of 139.5, which is about double normal.

I have included the laboratory studies for you to review. His vitamin B12 level was normal at 282. He is somewhat reluctant to see a hematologist. I told him that you may recommend a bone marrow exam. At this point, he is feeling well and does not understand why he would nee to see another physician.

I appreciate your evaluation.


Dr. Suess

Return to top

History of Present Illness: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia. Past Medical History: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.

Medications: None.

Allergies: No known drug allergies.

Social History: He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.

Family History: Unremarkable.

Physical Examination:
General: This is a thin, black cachectic man speaking in full sentences with oxygen.
Vital Signs: Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT: Funduscopic examination normal. He has oral thrush.
Lymph: He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
Neck: No goiter, no jugular venous distention.
Chest: Bilateral basilar crackles, and egophony at the right and left middle lung fields.
Heart: Regular rate and rhythm, no murmur, rub or gallop.
Abdomen: Soft and nontender.
Genitourinary: Normal.
Rectal: Unremarkable.
Skin: The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms.

Laboratory and X-Ray Data: Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. Hemoglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1, AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.

1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Thrush.
3. Elevated unconjugated bilirubins.
4. Hepatitis.
5. Elevated globulin fraction.
6. Renal insufficiency.
7. Subcutaneous nodules.
8. Risky sexual behavior in 1982 in Haiti.

1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Begin intravenous Bactrim and erythromycin.
3. Begin prednisone.
4. Oxygen.
5. Nystatin swish and swallow.
6. Dermatologic biopsy of lesions.
7. Check HIV and RPR.
8. Administer Pneumovax, tetanus shot and Heptavax if indicated.

Return to top
1. Cerebrovascular accident.
2. Schizophrenia.
3. Recurrent transient ischemic attacks.

1. Echocardiogram.
2. Holter monitor.

This is a 59-year-old, right-handed woman with a history of hypertension, schizophrenia, and a fallopian ovarian tumor resecte surgically and with radiotherapy treatment, who presented to the emergency room with a four-hour history of difficulty talking, and numbness and weakness on the right side. She was in her usual state of health until early the morning of admission when she woke up and noted numbness on her right side. Her numbness was associated with weakness as well as difficulty speaking, with no associated headache, chest pain, fever, chills, double vision difficulty swallowing or palpitations. She reported having a similar incident about one month prior to admission when she was seen in the emergency room, but at that time, her symptoms resolve while in the emergency room. CT scan at that time showed bilateral basal ganglion infarcts. Carotid duplex then showed minimal plaque, rig ht greater than left, with no hemodynamic stenosis. At that time, she was sent home on aspirin 1 q.d. which she has been taking except for the day prior to admission when she missed her dose.

VITAL SIGNS: Temperature of 37.1, blood pressure of 164/100 in both arms.
HEENT: Clear.
NECK: Mild right bruit.
HEART: Regular rate and rhythm with no murmurs.
LUNGS: Clear.
ABDOMEN: Obese with a surgical scar. Bowel sounds were present.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: She was alert and oriented times three. She had difficulty with speech, mostly lingual sounds. No aphasic symptoms. Normal flow, normal rate and normal content. No breathlessness noted. Cranial nerves showed right fundi with sharp discs, pupils reactive 3 to 2 bilaterally, full extraocular movements and full visual fields. Corneal reflexes were present bilaterally. Decreased V1 through V3 pinprick on the face. Masticatory muscles were normal. Face was symmetric. Eye closure, puffed cheeks and smile were symmetric. Uvula and tongue were midline. Her gag was present bilaterally, left greater than right. Motor examination showed increased tone in the left arm. Strength was 4/4 in the right upper and lower extremities and 5/5 in the left upper and lower extremities. Reflexes were 2+ throughout with downgoing toes. Sensory examination showed decreased pinprick on the right side. There was decreased vibration bilaterally in upper and lower extremities. Normal stereognosis and graphesthesia. Gait: She was able to bear weight on the left with some difficulty.

LABORATORY DATA: Unremarkable. Head CT scan at the time of admission showed bilateral lacunae of the anterior internal capsule with basal ganglion involvement; no change from prior CT scan. Electrocardiogram showed normal sinus rhythm at 81 with Q-waves in leads I and aVL, and small Q-waves in V1 and V6.

HOSPITAL COURSE: The patient was admitted to the neurology service with concern for an embolic versus ischemic event in the face of aspirin therapy. As an inpatient, she had an echocardiogram which was reported to show mild, concentric, left ventricular hypertrophy with normal left ventricular function, no segmental wall abnormalities, no mitral regurgitation, no aortic regurgitation and no tricuspid regurgitation. No evidence of coral thrombus. Carotids were not repeated, since she had a carotid study one mont prior to admission that showed an occlusion of her carotids. RPR was nonreactive. Blood pressure remained under control during hospitalization. Her psychiatric symptoms were stable during this time. She was seen by physical therapy and occupational therap who helped her with ambulation, and by discharge she was making good progress, ambulating and using her arms, although she remained with weakness on the right more marked than the left. She was discharged in good health.

1. Nortriptyline 25 mg p.o. q.h.s.
2. Benadryl 50 mg p.o. q.h.s.
3. Navane 5 mg p.o. q.h.s.
4. Aspirin 2 p.o. b.i.d.

1. Diet: Low-cholesterol, low-fat diet.
2. Activity: As tolerated.

1. Followup with physical therapy and occupational therapy.
2. Return to the neurology clinic about one month after discharge.

Return to top
  • Return to top
  • Return to Samples of Transcribed Medical Documents