SOAP Note Report Sample:

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RE:   David Jones
DATE 12/01/12
MR:  240804
DOB: 12/01/65

S:  The patient presents for a physical.  The back pain has been present for just a few days and is slightly worse with movement.  He has had pains in his elbows for approximately four months.  It is relatively constant, no extreme.  It does tend to hurt when he supinates his forearm fully.  He has also had some mild pain in the back.  At one time, he was thought to possibly have cervical disc disease; however, a CT scan of the cervical spine was unremarkable.  He has no other significant history.  Social:  He is a nonsmoker. Family history:  His father does have some mild arthritis and also has hypertension and heart disease.

O:  HEENT:  Tympanic membranes are clear bilaterally.  Nose and throat are clear.  Neck is supple without lymphadenopathy or bruits.  Cardiovascular:  Regular rate and rhythm without murmur.  Abdomen:  Soft, flat, nontender, and nondistended.  Bowel sound are active.  He has some minimal tenderness in the right lower quadrant.  Back: There is trigger-point tenderness.  Lower extremities are normal to exam.  He has negative straight leg raising in the supine position.
Laboratory studies were within normal limits, with the exception of his cholesterol which was 236 and his triglycerides which were 320.  He is not watching his diet at all.

A:  Strain of the lower back.  I think this may well be due to his work as a clerk.  He spends a lot of time at a computer keyboard.

P:  He is to take the strain off of his elbows and lower back.  I also gave him an instruction sheet on a low-cholesterol diet.  He will try to follow this for six months, and we will recheck his cholesterol then.  He asked if I would recommend taking niacin.  I told him that it might have some beneficial effect and was probably relatively safe for him to take.