Medical office note samples:
OFFICE NOTE SAMPLE #1
I had the pleasure of seeing the patient back again on 01/04/07. He has not obtained diabetic shoes at this point. He has pain in both feet and his low back. He is on Motrin.
His exam demonstrates a healing ulcer on the plantar aspect of the right IP joint. There is overlying callus fissures, no evidence of infection and decrease in size.
1. Diabetic wound right foot.
PLAN: The wound is debrided and the patient is given instructions to the wound care. He desperately needs diabetic shoe year. We will talk about this again. I will see if I can see her in two weeks to see her with a more active role.
OFFICE NOTE SAMPLE #2
HISTORY: Debra returns today after a visit with Dr. Harry Richard. At that time he suggested cervical epidural steroid injection. The patient was given Percocet 7.5/325 to take prior to the procedure. She did not schedule the procedure because her symptoms decreased. The pain level at the present time is 3-4/10 with pain that is extending to the right upper extremity from the right shoulder on the lateral and the anterior aspect of the upper arm to the elbow but not into the hand. She gets occasional paresthesias in the right thumb but no apparent weakness.
PHYSICAL EXAMINATION: Reflexes intact bilaterally in the biceps, triceps, and brachioradialis. No difficulty with position of the first and second fingers. Mobility of the fingers, wrists, elbows, shoulders were all within normal limits. Examination of the neck by palpation: No pain on palpation of the superior transverse processes. There is paravertebral muscle tenderness at C5-C6 bilaterally but no suprascapular tenderness. Cranial nerves II-XII appear intact.
1. Displaced disc at C-C6.
2. C5-C6 radiculopathy.
PLAN: Continue Percocet and continue physical therapy. She has finished chiropractic therapy. She was warned about signs of increasing weakness such as inability to hold objects in her hand and difficulty moving her right thumb. Should anything occur like that or any weakness she will return immediately. In the meantime, she will be treated with medications and physical therapy. We will consider epidural steroid injections if symptoms worsen.
OFFICE NOTE SAMPLE #3
HPI: He is an established patient of the practice, last seen a little over a year ago. Subjectively, he is an 82-year-old male with chronic left knee pain due to degenerative joint disease. He has been treated extensively none operatively with physical therapy, home exercises, cortisones injections, Synvisc injections, as well as the use of a cane. He comes in wondering if there anything out there that is new day as he is not a candidate for an arthroplasty. Objectively, the examination of the left knee reveals that he does have an immobile brace right now. He has pain with range of motion of the knee. He is grossly neurovascularly intact distally otherwise. X-ray examination performed today of the left knee reveals that he has significant medial compartment and patellofemoral compartment degenerative joint disease.
ASSESSMENT AND PLAN: Continue physical therapy and Naprosyn. Also, I did offer her a back support today to use when her back bothers. We will get her a Warm & Form type of brace. She is going to follow-up with me in one month’s time for another clinical evaluation.
OFFICE NOTE SAMPLE #4
Right knee pain.
The patient is a 59-year-old Caucasian female, with right knee pain and off for the last 8 years. She states that the pain increases with activities and decreased with activities. It decreases with rest. She states that her pain level is 5/10. She states that she has good days and bad days. The patient states that she has night pain. The patient has stiffness. The patient denies catching, popping or locking. The patient states that she has difficulty getting out of a chair, getting out of a car, sitting, standing and walking, both on flat and incline surfaces. She has been treated with Relafen, Celebrex and Motrin over the years with minimal effect. Examination of the right knee demonstrates no effusion. The knee is in 10 degrees of varus. There is medial and lateral joint line tenderness. There is reduced painful forced flexion. Extension is full. There is a negative Lachman test. The patella is nontender.
X-RAY: X-ray of the right knee done on 9-16-06 demonstrates decreased medial joint space, subchondral sclerosis and spiking of the tibial spines. These findings are compatible with degenerative joint disease.
1. Degenerative joint disease right knee.
TREATMENT: The knee was sterilely prepped and injected with steroid and Lidocaine preparation. She is given a prescription for physical therapy for the right knee. She will not wear any form of immobilization, since she has changes of chronic venous disease and has had a saphenous vein stripping in the past. She will be seen again in four weeks.
The patient was given a prescription for Relafen 750 mg, b.i.d.
OFFICE NOTE SAMPLE #5
She returns today for follow-up of low back pain and a new problem with her right foot and ankle. Concerning her low back pain, she still has it. It radiates to her left leg. She tells me that she is scheduled to see her PCP next week. She has intermittent pain pointing to the area of the talonavicular joint of her right foot. She has had polio. She has had a triple arthrodesis 40 years ago. She is having intermittent pain about five times over the last month. It is difficult to walk when she gets it
Examination demonstrates tenderness over the talonavicular joint.
Plain x-rays show the subtalar and calcaneonavicular joint solidly fused as some joint space that is visible of the talonavicular joint has a cyst in the neck of the talus.
We will get an open MRI to further evaluate this area in fine detail. We will ask her to wear a cam walker for pain relief with ambulation.
We will see her back in four weeks.
Office Visit Report Sample #6
Reason for OV: Neck, shoulder and low back pain.
This is a 68-year-old female PMH, generalized OA, cervical lumbar DDD, DJD and fibromyalgia returns after 2 ½ month without reporting any incidents of problems with pain until the last 3 or 4 weeks. She has dull achy pain in her neck, across her shoulder into her low back. Both areas the pain feels similar in quality and also feels very similar in quality to the pain that she had September of this year when Dr. Griffin gave her suprascapular nerve blocks. This pain becomes burning with certain head and neck movements. She has recently been on the Lyrica in stead of p.r.n. 50 mg b.i.d. for about the last 3-4 weeks. She is not really sure if the Lyrica is helping. She has been trying heat which helps a little bit but she hurts all over and it is “really bad”. She denies any weakness, numbness, pins and needles but this pain does get worse with head, neck and shoulder movements. Medications are reviewed.
PE: Vital signs: BP 100/70. P 72. R 16. Wt: 164 lbs. Patient is WD/WN, overweight and in NAD. A&O x 3. Mood and affect is flattened. HEENT: Unremarkable. Heart: RRR. Lungs: CTA. Abdomen: Protuberant but benign. Patient is neurovascularly intact. Gait is normal. Musculoskeletal: She has no signs of inflammation. There is no erythema, ecchymosis or swelling. She definitely has the “touch me not” syndrome. Upper body is dominant. She has multiple trigger point tenderness in the upper extremities and low back. None in the lower extremities.
ASSESSMENT AND PLAN:
1. Bilateral shoulder and neck pain secondary to trapezial muscle spasming and cervical muscle spasming with fibromyalgia flare.
Procedure note: Bilateral suprascapular nerve blocks were performed using Kenalog 30 mg with 3 cc of 1% Xylocaine injected under sterile technique into the suprascapular notch. Patient tolerated the procedure well and reported significant improvement in pain prior to leaving. She will continue to use the Lyrica 50 mg b.i.d. She has a follow-up appointment scheduled with Dr. Griffin in approximately two weeks. We will keep that appointment for now. If she is not better she will see him. If she is better she will call and cancel
2. Low back pain secondary to DDD and degenerative sacroiliitis.
Procedure note: Bilateral SI joint injections were performed using Kenalog 30 mg with 2 cc of 1% Xylocaine injected using a sterile technique. Patient tolerated the procedure well.
3. Hypogonadism. Patient is postmenopausal. Does not have a family history for osteoporosis as near as I can tell she is a nonsmoker. Both by her admission and previous medical records she may want to consider a DEXA and check vitamin D level. Extended visit.