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The document summarizes medical records for three patients. For the first patient, Mr. Adam Carl, sutures were removed from a healed eye laceration without issue. For the second patient, Edward Reiss, sutures were removed from a healed left knee wound. For the third patient, Jason R. Jones, a 15-month well-baby examination found normal development and growth, with immunizations administered.

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4K views

Soap Notes

The document summarizes medical records for three patients. For the first patient, Mr. Adam Carl, sutures were removed from a healed eye laceration without issue. For the second patient, Edward Reiss, sutures were removed from a healed left knee wound. For the third patient, Jason R. Jones, a 15-month well-baby examination found normal development and growth, with immunizations administered.

Uploaded by

api-383904539
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patient Name: Mr.

Adam Carl
Date of Birth: 04/22/xxxx

SUBJECTIVE:
Suture removal. Patient returns for removal of stitches placed about seven days ago.

OBJECTIVE:
Wound at lateral aspect of the left eye looks well healed. The 5-0 nylon sutures were removed without
difficulty.

ASSESSMENT:
Laceration, healed.

PLAN:
I advised him to use Vitamin E for scar prophylaxis

Jason Karns, MD/xx


Patient Name: Edward Reiss
Date of Birth: 07/05/xxxx

SUBJECTIVE:
Patient came in for suture removal from a left knee wound. He is doing well.

OBJECTIVE:
Wound appears dry and clean; there are no signs of infection.

ASSESSMENT:
Suture removal.

PLAN:
All 5 sutures were removed. Bandage was applied.

Jason Karns, MD/xx


Patient Name: Jason R. Jones
Date of Birth: 03/02/xxxx

SUBJECTIVE:
Michael comes in today for a 15-month examination. Mother has no complaints. He is feeding himself
and putting two words together when talking. For motor and growth development, he is actually in the
22-month development. Most recent hemoglobin was 12.3. His is above the 95th percentile for height;
95th percentile for weight.

OBJECTIVE:
Head is normal. Ears are clear. Pupils are equal, round, and reactive to light and accommodation. Throat
is clear. Nose is clear. Eyes are clear. Neck has good range of motion without nodes. Lungs are clear.
Heart has regular rate and rhythm. Abdomen is soft without masses. Testicles are descended. Back is
straight. He is walking well. He has good muscle tone. See developmental forms in chart.

ASSESSMENT:
Normal well-baby examination.

PLAN:
Continue present diet and advance as tolerated. Immunizations were given; see form. Recheck in 3
months, sooner if needed.

Jason Karns, MD/xx

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