SUBJECTIVE: The patient is here for followup of an infected (1)_________, which was removed. The (2)________ was removed last week, and the wound was noted to be erythematous with mild (3)________ discharge and warmth. Patient was placed on Keftab. Patient took her last Keftab today. She states the lesion is nontender. It has had no discharge or warmth. Patient also needs a refill of her Celexa today.
OBJECTIVE: Left posterior neck has an appropriately healing (4)________, which is status post EIC with suture removal. There is no erythema, edema, warmth, or discharge.
ASSESSMENT/PLAN:
1. Status post epidermal (5)__________ cyst removal with appropriately healing lesion. No specific treatment at this time.
2. Depression. Celexa 20 mg daily, 90, refill given. Follow up on p.r.n. basis.
Question 2
SOAP NOTE
SUBJECTIVE: Patient is here for followup of a left lower leg (1)__________ phlebitis. She was placed on aspirin therapy and an (2)__________ wrap at that time. The patient states that she has a long history of (3)__________ veins, which are painful, especially after standing for prolonged periods. She is inquiring as to whether or not she is a surgical candidate for this. Patient denies any chest pains, shortness of breath. She denies any warmth to the area and states that the acute tenderness she had over the (4) __________ is now resolved. The patient also has some TED hose with her today, which she wanted to see if the size is appropriate for her.
OBJECTIVE: Lower extremities: The left lower leg on the upper medial portion of the calf extending above the knee has significant varicose veins, which are very (5) __________. These are not painful to touch. There is no warmth or (6) __________associate d with this. There is no (7) __________ firmness or clot noted. There are standard varicosities of both lower extremities, some of lesser and some of equal degree. The patients (8) __________ hose were placed on her and are the appropriate size for her.
ASSESSMENT/PLAN: Left lower extremity (9) __________, which are symptomatic and significant enough for surgical evaluation and, most likely, surgical treatment. The patient will continue with her (10) __________ therapy as previously directed. She may wear the TED hose and is referred to Surgery for definitive evaluation and treatment. Patient agrees with plan.
Patient with a cerebrovascular accident.
Patient teaching: nose and sinus assessment
Medical assistants can quickly pull up a patient record when a phone call is received.
Reputable Websites for Patient Education
A histologic slide showing the sponge-like architecture of a patient with Creutzfeldt-Jakob Disease.
A patient is talking to the nurse about her husband’s abuse and attempt to strangle her. She ...