Sample SOAP: Multiple problems

SUBJECTIVE:

M.R. is a 62-year-old retired mathematics professor who presents to clinic today for three reason.

Foremost, he presents with concern of a two-day history of pain at the base of his right great toe. Previously well in this regard. He states the pain woke him from sleep two night ago. He states the pain has been “incredible”. Pain well localized to the base of his right great toe. Constant. “Unable to even put a sock on”. Subsequently, he has noticed redness and warmth at the MTP. He has applied ice without benefit. He has taken Tylenol at therapeutic doses without any appreciable reduction in pain. He denies pain or redness at any other joints. He denies fever or chills. He denies any known injury. No history of rheumatologic disease. Of note, he carries no diagnosis of gout, but he reports that his uric acid level at a health fair screening 6 months prior was “eight something”. He reports drinking “one can of beer per week”. He reports being mostly compliant with a Mediterranean Diet. No recent decrease in fluid intake.

He also presents with concern of a roughly one-week history of intermittent left lower abdominal pain. He feels well at present in that regard, but roughly every other day for the past week he has had “burning pain” in his left lower quadrant. He states the pain is moderately severe. Some radiation to his left lower back. He reports having long-standing intermittent constipation for which he takes Miralax as needed. He has strained at stool in the past week. No pain with defecation, but sometimes the lower abdominal pain prompts him to try to move his bowels. He reports passage of a small amount of presumed blood. Again, no recent fever. No nausea, vomiting, or diarrhea. No urinary symptoms. No history of hemorrhoids or diverticulitis. He reports undergoing screening colonoscopy at age 52. He reports “Everything looked good” (records unavailable). No family history of colorectal cancer. No history of abdominal surgery.

Finally, M.R. presents for ongoing management of long-standing, well-controlled hypothyroidism. He states that ten years ago he presented to his physician with concern of fatigue and constipation. Diagnostic evaluation revealed an elevate TSH of “about 20” (records unavailable). He started taking levothyroxine. He has taken levothyroxine 150ugm/day for the past 6 years. Some ongoing constipation as noted above, but he denies undue fatigue, dry skin, or weight change. His most recent TSH was one year prior. Review of his lab results shows his TSH was 1.86. Free T4 not performed.

Medications:

Levothyroxine 150mg by mouth once per day as above.

OTC Multivitamin 1 by mouth per day,

OTC Miralax as needed to treat constipation as per above.

OBJECTIVE:

Vital signs:    37.5C    128/82    72 beats/minute    14 breaths/minute    BMI 28.8

General: Walks with a limp. Wearing open toed sandals. Pleasant. Sense of humor intact.

Neck: No obvious goiter. No palpable thyromegaly or palpable thyroid nodules. No palpable neck lymphadenopathy. No tenderness to palpation. No exophthalmos.

Cardiopulmonary: Clear to auscultation in all lung fields. Regular rate and rhythm. Normal S1/S2. No ectopy. No murmur/rub/gallop.

Abdomen: He moves easily from sitting to reclining to sitting. Abdomen without distention. Normal bowel sounds. No apparent hepatosplenomegaly. Some tenderness to deep palpation in the LLQ. No palpable masses. No guarding/rebound. Perianal skin without maceration or skin changes. No external hemorrhoids. Normal rectal tone. Some discomfort, but no pain with DRE. No palpable rectal masses. Some hard stool in the vault. No frank blood, but stool guaiac positive.

Lower Extremities: Right 1st MTP swollen with red and warm overlying skin. No evidence of puncture wound or break in skin continuity. Pain worsened with light touch of the joint and with any degree of flexion/extension. Contralateral MTP normal. No nail dystrophy. No pedal edema.

ASSESSMENT/PLAN: