Medical Transcription Sample Reports

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Vascular Surgery SOAP Note Medical Transcription Samples

SUBJECTIVE:  The patient is a (XX)-year-old man with a history of chronic venous insufficiency and a prior venous ulcer. He returns today for a preoperative evaluation prior to undergoing right greater saphenous vein stripping. He had a right ankle ulcer due to chronic venous hypertension that began last year. After a period of treatment with conservative management, using compression therapy, the ulcer ultimately healed. A vein valve duplex study of the right leg demonstrated incompetence of right greater saphenous vein beginning at the saphenofemoral junction extending down through the thigh. Deep vein valve closure times were normal. Right greater saphenous vein stripping and ligation was recommended to prevent recurrent ulceration. The patient has a history of varicose veins dating back many years and underwent bilateral lower extremity varicose vein surgery previously. He has, otherwise, been in good health and has no other active medical problems and is on no medications.  There is a family history of venous varicosities. No family history of bleeding or clotting abnormalities.

OBJECTIVE:  The patient is a (XX)-year-old man who appears his stated age. He is awake and alert. Blood pressure is 134/98. Pulse is 86 and regular. Lungs are clear. Heart sounds normal, regular. Examination of the legs reveals venous varicosities in the greater saphenous distribution of the right leg with significant trophic changes of chronic venous hypertension in the lower leg.

ASSESSMENT AND PLAN: In summary, the patient has right greater saphenous venous valvular incompetence. We have recommended a right greater saphenous vein stripping and ligation to lower his risk of recurrent venous ulceration. We have gone over the risks of the procedure in detail with him. He has signed a consent form today. His operation is scheduled sometime in the near future as an outpatient. We have asked him to avoid taking aspirin or anti-inflammatory medications within one week of the operation.

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SUBJECTIVE:  The patient is a (XX)-year-old man referred for an opinion regarding left leg DVT. He has been in good health, but developed a stress fracture of the left foot six months ago, resulting in placement of a cast. The cast was on for three months or so, and around that time, the cast was removed. He had some problems with swelling of the left leg. A subsequent left leg ultrasound demonstrated evidence of acute thrombosis of the left popliteal veins as well as thrombus in one of the tibial veins in the calf. The patient was then placed on anticoagulation, first with Lovenox and eventually warfarin. He has remained on warfarin up to the present time. He initially had some swelling in the leg, but his swelling has gotten better. He still has some problems with the foot, particularly some discomfort with weightbearing and some decrease in mobility in the foot, most likely referable to his forefoot stress fracture.

OBJECTIVE:  On physical exam, the patient is a (XX)-year-old man who appears his stated age. He is awake and alert. Blood pressure is 122/86. Pulse is 78 and regular. Lungs are clear to auscultation. Heart tones are regular. Abdominal exam reveals a soft, nontender abdomen. His aortic pulsation feels normal. Femoral, popliteal, and pedal pulses are palpable bilaterally. There is some very mild swelling in the left ankle and foot, but no swelling in the calf. He has no venous varicosities or stigmata of chronic venous hypertension.

ASSESSMENT AND PLAN:  In summary, the patient is a (XX)-year-old man with a left popliteal and calf vein deep venous thrombosis, most likely due to immobilization of the left leg due to a foot fracture and casting. Based on his physical exam, he does not have a significant venous outflow obstruction since there is minimal to no swelling at this point. We told the patient that we agree with the current management plan, which includes a period of three to six months of anticoagulation with warfarin. We would recommend a popliteal ultrasound at three months to look for vein recanalization. Following the period of anticoagulation, a knee-high support stocking would be helpful to prevent sequelae of chronic venous hypertension from post-thrombosis valvular dysfunction. We will plan to see the patient back on a p.r.n. basis. The patient seems satisfied with this plan and recommendation.

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SUBJECTIVE:  The patient returns with recurrent varicose veins in her left leg. We did bilateral ligation and stripping of branch varicose veins 10 years ago. Six years ago, she had bilateral recurrence. Three years ago, she underwent bilateral stab phlebectomy again. The patient said she had done well until about a year ago when she started developing recurrences on her left leg only. They cause stinging and burning. She has worn sports stocking, but they do not help. These are 20 and 30 mmHg compression stockings of both knee high and thigh high. The patient has been wearing this for the last six months. The symptoms are getting worse and the size and number of the varicosities has also worsened.

OBJECTIVE:  On exam, the right leg is normal. The left leg has normal pulses with no skin changes. There are bulging tortuous varicosities on her anterior, lateral, and medial thigh and leg. These are 5 to 8 mm in diameter. The greater saphenous vein is not palpable or visible.

ASSESSMENT AND PLAN:  We discussed the treatment options again. We discussed stab phlebectomy as the best option. We think these are too many and too large for sclerotherapy.

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SUBJECTIVE:  The patient is status post left superficial femoral artery to PT bypass graft and open left fourth TMA. He was recently seen, at which time he had arterial noninvasive vascular studies, which showed patent left proximal superficial femoral artery to PT bypass graft with mid-graft velocity 58 cm/sec and triphasic flow until the distal bypass graft, was monophasic, and had increased velocity up to 215 cm/sec at 20 cm below the knee and this was not changed from previous. Also, increased velocity up to 294 cm/sec at the distal anastomosis, which is essentially otherwise not changed. The patient is without complaints. He does not walk. He is in a wheelchair.

OBJECTIVE: Today, his foot is warm. His incisions are well healed. His TMA site is now covered with a dry eschar. A long segment of eschar, approximately 4.2 to 4.5 cm x 1 cm debrided. The skin underneath is intact. There is no open area. This area is cleansed with Betadine swab.

ASSESSMENT AND PLAN:  The patient is doing well and stable. He is instructed for a dry dressing to this area, of the left foot transmetatarsal amputation site for protection. He does have a followup appointment at which time he will have noninvasive vascular study repeated. He does not need to follow up until this point, unless he has any problems or questions or any signs of infection or open wounds.