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.