Transcription -Chart Notes-23

Sample Type: SOAP - Chart Notes
Sample Name: Gen Med Progress Note - 4
Description: The patient is in complaining of headaches and dizzy spells.
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Transcription -Chart Notes-22

Sample Type: SOAP - Chart Notes
Sample Name: Gen Med Progress Note - 3
Description: Sample progress note - Gen Med.
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Transcription -Chart Notes-21

Sample Type: SOAP - Chart Notes
Sample Name: Gen Med Progress Note - 2
Description: Sample progress note - Gen Med.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Followup on hypertension and hypercholesterolemia.

SUBJECTIVE: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson. He is known to have Crohn's and he takes care of that for him. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles.

MEDICATIONS: Refer to chart.
ALLERGIES: Refer to chart.

PHYSICAL EXAMINATION:

Vitals: Wt; 172 lbs, up 2 lbs, B/P; 150/60, T; 96.4, P; 72 and regular.
General: A 78-year-old male who does not appear to be in any acute distress. Glasses. Good dentition.
CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.
Lungs: Diminished with increased AP diameter.
Abdomen: Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.
Extremities: Well-healed surgical scar on the right knee. No edema. Hand grasps are strong and equal.
Back: Surgical scar on the lower back.

Neuro: Intact. A&O. Moves all four with no focal motor or sensory deficits.

IMPRESSION:
1. Hypertension.
2. Hypercholesterolemia.
3. Osteoarthritis.
4. Fatigue.

PLAN: We will check a BMP, lipid, liver profile, CPK, and CBC. Refill his medications x 3 months. I gave him a copy of Partners in Prevention. Increase his Altace to 5 mg day for better blood pressure control. Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.

Transcription -Chart Notes-20

Sample Type: SOAP - Chart Notes
Sample Name: Gen Med Progress Note - 10
Description: 5-month recheck on type II diabetes mellitus, as well as hypertension.
(Medical Transcription Sample Report)

SUBJECTIVE: The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain range of motion does cause it to hurt. No weakness, numbness or tingling. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns. Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.

ALLERGIES: None.

MEDICATIONS: She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.


SOCIAL HISTORY: She is a nonsmoker.

REVIEW OF SYSTEMS: As noted above.

OBJECTIVE:
Vital Signs: Temperature: 98.2. Pulse: 64. Respirations: 16. Blood pressure: 110/56. Weight: 169.
General: Alert and oriented x 3. No acute distress noted.
Neck: No lymphadenopathy, thyromegaly, JVD or bruits.
Lungs: Clear to auscultation.
Heart: Regular rate and rhythm without murmur or gallops present.
Breasts: Exam performed with a female nurse present. The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery. There is no axillary adenopathy or tenderness. Breasts appear to be symmetric. There was no nipple discharge or retraction. No breast tissue retraction noted in either the sitting or the supine position. Upon palpation there were no palpable lumps or bumps and no palpable discharge.
Musculoskeletal: She did have full range of motion of her shoulders. She did have tenderness upon palpation over the right bicipital tendon. There is no swelling, crepitus or discoloration noted.

MEDICAL DECISION MAKING: Most recent hemoglobin A1c was 5.6% back in October 2004. Most recent lipid checks were obtained back in July 2004. We have not had this checked since that time.

ASSESSMENT:
1. Type II diabetes mellitus.
2. Hypertension.
3. Right shoulder pain.
4. Hyperlipidemia.

PLAN:
1. She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.
2. We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.
3. I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.
4. She is going to follow up in the clinic in three months for a complete comprehensive examination. If any questions, concerns or problems arise between now and then she should let us know.

Transcription -Chart Notes-20

Sample Type: SOAP - Chart Notes
Sample Name: Gen Med Progress Note - 1
Description: Sample progress note - Gen Med.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Followup on diabetes mellitus, status post cerebrovascular accident.

SUBJECTIVE: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.

MEDICATIONS: Refer to chart.

ALLERGIES: Refer to chart.

PHYSICAL EXAMINATION:
Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.

General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition.
Skin: Dry and flaky.
CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right.
Lungs: Diminished but clear.
Abdomen: Scaphoid.
Rectal: His prostate check was normal per Dr. Gill.
Neuro: Sensation with monofilament testing is better on the left than it is on the right.


IMPRESSION:
1. Diabetes mellitus.
2. Neuropathy.
3. Status post cerebrovascular accident.

PLAN: Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.

Transcription -Chart Notes-19

Sample Type: SOAP - Chart Notes
Sample Name: Foot Pain - SOAP
Description: Patient having foot pain.
(Medical Transcription Sample Report)

SUBJECTIVE: This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that Project Access is trying to find her a doctor. She is not currently on Project Access, and so she is here to get something for the pain in her foot. I did notice that she went in to see Dr. XYZ for a primary care physician on 01/14/2009. She said she does not have a primary care physician. She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers. She has been in here multiple times for different kinds of pain. This pain she is having is in her foot. She had surgery on it, and she has plates and screws. She said she was suppose to see Dr. XYZ about getting some of the hardware out of it. The appointment was cancelled, and that is why she came here. It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her. She did not injure her foot in any way recently. It is chronically painful. Every time she does very much exercise it hurts more. We have x-rayed it in the past. She has some hardware there. It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.


PHYSICAL EXAM: Examination of her foot shows some well-healed surgical scars. On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar. They are all old, and the surgery was done over a year ago. She is walking with a very slight limp. There is no redness. No heat. No swelling of the foot or the ankle. It is mildly tender around the medial side of the foot just inferior to the medial malleolus. It is not warm or red.

ASSESSMENT: Foot pain.

PLAN: She has been in here before. She seems very pleasant. Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill. After she left, I got to thinking about it and looked into her record. She has been in here multiple times for pain medicine. She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago. We called Dr. XYZ office. Dr. XYZ nurse said that the patient did not have an appointment today. She has an appointment on March 15, 2009, for a postop check. They did not tell her they would not see her today because of insurance, so the patient was lying to me. We will keep that in mind the next time she returns, because she will likely be back. She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.

Transcription -Chart Notes-18

Sample Type: SOAP - Chart Notes
Sample Name: Fifth Disease - SOAP
Description: Fifth disease with sinusitis
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SUBJECTIVE: Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school. She says it itches and they have been doing some Benadryl for this. She has not had any wheezing lately and is not taking any ongoing medications for her asthma.

PAST MEDICAL HISTORY: Asthma and allergies.

FAMILY HISTORY: Sister is dizzy but no other acute illnesses.

OBJECTIVE:
General: The patient is an 11-year-old female. Alert and cooperative. No acute distress.
Neck: Supple without adenopathy.
HEENT: Ear canals clear. TMs, bilaterally, gray in color and good light reflex. Oropharynx is pink and moist. No erythema or exudates. She has postnasal discharge. Nares are swollen and red. Purulent discharge in the posterior turbinates. Both maxillary sinuses are tender. She has some mild tenderness in the left frontal sinus. Eyes are puffy and she has dark circles.

Chest: Respirations are regular and nonlabored.
Lungs: Clear to auscultation throughout.
Heart: Regular rhythm without murmur.
Skin: Warm, dry and pink. Moist mucous membranes. Red, lacey rash from the wrists to the elbows, both sides. It is very faint on the lower back and she has reddened cheeks, as well.

ASSESSMENT: Fifth disease with sinusitis.

PLAN: Omnicef 300 mg daily for 10 days. May use some Zyrtec for the itching. Samples are given.

Transcription -Chart Notes-17

Sample Type: SOAP - Chart Notes
Sample Name: Down’s syndrome
Description: A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.
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SUBJECTIVE: This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April, I also found that he was hypothyroid with elevated TSH. He was started on Levothroid 0.1 mg and has been taking that daily. We will recheck a TSH today as well. His mother notes that although he does not like to take the medications, he is taking it with encouragement. His only other medications are some eyedrops for his cornea.

OBJECTIVE: Weight was 149 pounds, which is up 2 pounds. Blood pressure was 120/80. Pulse is 80 and regular.
Neck: Supple without adenopathy. No thyromegaly or nodules were palpable.

Cardiac: Regular rate and rhythm without murmurs.
Skin: Examination of the toenails showed really no change yet. They are still quite thickened and yellowed.

ASSESSMENT:
1. Down’s syndrome.
2. Onychomycosis.
3. Hypothyroidism.

PLAN:
1. Recheck ALT and TSH today and call results.
2. Lamisil 250 mg #30 one p.o. daily with one refill. They will complete the next eight weeks of therapy as long as the ALT is normal. I again reviewed the symptoms of liver dysfunction.
3. Continue Levothroid 0.1 mg daily unless dosage need to be adjusted based on the TSH.

Transcription -Chart Notes-16

Sample Type: SOAP - Chart Notes
Sample Name: Dietary Consult - Weight Reduction
Description: Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.
(Medical Transcription Sample Report)

SUBJECTIVE: This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendations to assist both of them in healthier eating. The two of them live alone now, and she is used to cooking for large portions. She is having a hard time adjusting to preparing food for the two of them. She would like to do less food preparation, in fact. She is starting a new job this week.

OBJECTIVE: Her reported height is 5 feet 4 inches. Today’s weight was 170 pounds. BMI is approximately 29. A diet history was obtained. I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well. Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.

ASSESSMENT: The patient’s basal energy expenditure is estimated at 1361 calories a day. Her total calorie requirement for weight maintenance is estimated at 1759 calories a day. Her diet history reflects that she is making some very healthy food choices on a regular basis. She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals. She also is emphasizing lower fat selections. Her physical activity level is moderate at this time. She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend. We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction. We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well. We discussed menu selection, as well as food preparation techniques. The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that. I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.


PLAN: Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk. Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week. This translates into a 1200-calorie meal plan. I encouraged the patient to keep food records in order to better track calories consumed. I recommended low fat selections and especially those that are lower in saturated fats. Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well. This was a one-hour consultation. I provided my name and number should additional needs arise.