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Orthopedic SOAP Note Medical Transcription Sample Report

SUBJECTIVE:  The patient presents in followup regarding his right leg injury. He is post injury day #9, status post irrigation and debridement of type 1 open right segmental distal tibial fracture, as well as closed treatment of right lateral tibial plateau fracture and application of a joint spanning external fixator. He has been at a skilled nursing facility. He has maintained nonweightbearing status in the right lower extremity. He is taking Lovenox 40 mg once daily for venous thromboembolism prophylaxis. He reports no problems with the pins. His pain has been well controlled. He denies any calf pain or swelling. He denies any fevers or chills or any other constitutional symptoms.

OBJECTIVE:  On examination of the right lower extremity, the tibial and femoral pin sites are clean, dry and intact. There are no local signs of infection. On examination of the knee, there is minimal soft tissue swelling. There are no fracture blisters. There is wrinkling over both the medial and lateral aspects of the proximal tibia. There is no calf pain or tenderness to palpation. There is moderate soft tissue swelling the distal third of the tibia. The anteromedial fracture blister, which was serous in nature has decompressed itself and is in the process of re-epithelializing. The foot is warm and well perfused with brisk capillary refill. The calcaneal pin site has minimal serous drainage. There are no local signs of infection. The skin is intact over the heel. Sensation is intact to light touch in the distribution of the sural, saphenous, superficial peroneal, deep peroneal, and tibial nerves. He is able to actively flex and extend the toes against gravity. There is no pain with passive stretch of the leg muscle compartments. There is a lack of wrinkling over the medial aspect of the ankle. There is evidence of skin wrinkling over the lateral aspect of the ankle. The traumatic open wound, which has been closed loosely, primarily, demonstrates no local signs of infection. There is no warmth or erythema or drainage.

Radiographs of the right knee and tibia and fibula demonstrate no change in position of the fractures.

ASSESSMENT AND PLAN:  Postoperative day #9, status post irrigation and debridement of type 1 right segmental distal tibia fracture, as well as application of a joint spanning external fixator for closed right proximal lateral tibial plateau fracture and segmental type 1 open distal tibia fracture. The diagnosis was described in detail to the patient. At the present time, his pin sites remain stable. He is to continue on Lovenox for venous embolism prophylaxis 40 mg once daily.

With regard to the second stage of treatment, at the present time, his soft tissue swelling over the proximal tibia has resolved. I do feel this is fit for open surgical repair. However, distally, the soft tissue envelope remains swollen and the medial blister continues to re-epithelialize. I feel at the present time, the soft tissue envelope over the distal tibia is unfit for surgery. I explained that after stabilization of the tibial plateau fracture, one of three methods will be used to stabilize the distal tibial fracture; plate osteosynthesis, definitive external fixation, intramedullary nailing. At the present time, however, the soft tissue envelope precludes any open type of surgery.

We will tentatively plan for open reduction and internal fixation of the right tibial plateau fracture to be performed on MM/DD/YYYY. At that time, depending on the soft tissue envelope distally, he may or may not have definitive surgical repair. Either way, he will have the knee spanning external fixator removed at that point and most likely have an adjustment made to the distal tibial external fixator. He understands the treatment plan as outlined above. I have given instructions to the rehabilitation facility to place only a dry dressing over the medial fracture blister as Xeroform will potentially cause excess moisture and maceration. He understands the treatment plan as outlined above.

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SUBJECTIVE:  This is a pleasant male who has a history of low-grade pain in the shoulder that is about 2/10. He has no numbness, tingling, or weakness. He has done no formal therapy. He takes some anti-inflammatories. No injections or surgeries. He does have GERD.

OBJECTIVE:  The patient is 5 feet 8 inches, 238 pounds. Well nourished, well developed, in no acute distress. Normal affect. Skin is intact. He does have good symmetric range of motion, good external rotation bilaterally, even in the abducted position it was fully symmetric. He has a positive Neer sign, less so Hawkins. He has some pain with a dynamic labral shear. Really no pain with the O'Brien's. He has no instability, negative apprehension and Jobe’s. He has no pain with load and shift. He has good strength with 5/5 forward elevation, external rotation, internal rotation, abduction. He is otherwise grossly neurovascularly intact.

X-rays are negative. MR arthrogram shows possible tear of the posterior inferior labrum, small changes in the supraspinatus, but no full-thickness tears.

ASSESSMENT AND PLAN: We had a long discussion regarding options, including leaving it alone, consideration of formal therapy program, as well as surgical intervention. At this point, he is going to go forward with therapy program. Certainly, does not want to do anything from a surgical standpoint. It does not bother him that badly at this point. We will see him back in a couple of months and see how he is doing. Certainly, if he wants to leave things alone, even if it does not get better, he can live with it. If things do not improve, we certainly can consider an arthroscopic evaluation, possible debridement or repair. If things worsen in the interim, he will call and we will see him sooner.

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