Sample Type: SOAP - Chart NotesSample Name: CervicalgiaDescription: Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.
(Medical Transcription Sample Report)
The patient is a 76-year-old retired female who is well known to our practice. She most recently underwent anterior cervical discectomy and fusion C3 through C7 on 09/06/2005. She was last seen in the office by Dr. L on 03/16/2006 with the anticipation of removing her anterior cervical plate for she was having a lot of difficulty with swallowing. The surgery was set up and scheduled, but the patient did not go through the surgery. She thinks that most recently in past couple of months she has been having more difficulty with her swallowing. She had a fall about two or three months ago and she states since that time she has had more pain in the back of her neck and more pain in her arms and difficulty swallowing. She has also seen a physician who states that she needs shoulder surgery. Her left is worse than the right and that they will be proceeding with that once she has had her cervical plate removed, so that she can have some normalcy to her swallowing. She states her pains are constant. On a 1-10 pain scale, she rates it as a 10. She takes hydrocodone for that. Dr. S ordered MRIs and x-rays. The patient brings in with her x-rays today but does not have her MRI. On the body image drawing, she draws head pain on the top of her head, bilateral upper trapezius pain, bilateral arm pain into the thumbs bilaterally, worse on the left with numbness and tingling in the lower arm. She is not able to identify an alleviating or aggravating factor. She describes the pain as being 80% in the neck and 20% in the left arm.
FAMILY HISTORY: Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both with cancer. She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.
SOCIAL HISTORY: She is married and has support at home. Denies tobacco, alcohol, and illicit drug use.
ALLERGIES: Aspirin.
MEDICATIONS: The patient does not list any current medications.
PAST MEDICAL HISTORY: Hypertension, depression, and osteoporosis.
PAST SURGICAL HISTORY: She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L. She is G10, P7, no cesarean sections.
REVIEW OF SYSTEMS: HEENT: Headaches, vision changes, dizziness, and sore throat. GI: Difficulty swallowing. Musculoskeletal: She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis. Respiratory: Shortness of breath and cough. Cardiac: Chest pain and swelling in her feet and ankle. Psychiatric: Anxiety and depression. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Genital: Negative and noncontributory.
PHYSICAL EXAMINATION: On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds. BP 138/78, pulse is 64. General: A well-developed, well-nourished female, in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth, she does have some poor dentition. She does say that she needs some of her teeth pulled on her lower mouth. Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation. EOMs are full bilaterally. Pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movements. Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically. Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry. Normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. She does have some tremoring of her bilateral upper arms as she said. Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted. She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.
It is much more painful for her on the left. Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles. No ankle clonus is elicited. Hoffmann's is negative bilaterally. Sensation is intact. She ambulates with slow short steps. No spastic gait is noted. She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane. She does not bring one in with her today.
FINDINGS: Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today. She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level. No fractures are noted.
ASSESSMENT: Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.
PLAN: We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm. She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available. She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery. All questions and concerns were addressed with her. Warning signs and symptoms were gone over with her. If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled. I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well. Case was reviewed and discussed with Dr. L.
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