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1,300 | Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. | SOAP / Chart / Progress Notes | Urinary Frequency & Urgency - Followup | HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improvement of her symptoms. The nursing home did not do a voiding diary. She is accompanied by her power of attorney. No dysuria, gross hematuria, fever or chills. No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION: ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. This has not improved on VESIcare as well as Enablex. Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure. The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today. Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided. They will see Dr. X with a prior voiding diary, which is again discussed. All questions answered.,PLAN:, As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney. In the meantime, Sanctura prescription is provided, and voiding diaries are provided. All questions answered. | soap / chart / progress notes, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding |
1,301 | The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse. | SOAP / Chart / Progress Notes | Urinary Retention - Followup | HISTORY OF PRESENT ILLNESS: , The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0. No incontinence. No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION: ,1. The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2. Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily. She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention. All questions answered. | soap / chart / progress notes, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence, |
1,302 | He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. | SOAP / Chart / Progress Notes | SOAP - Substance Abuse | SUBJECTIVE: , This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. He has a history of doing heroin. He was injecting into his vein. He was seeing a physician in the city. They were prescribing methadone for some time. He says that did help. He was on 10 mg of methadone. He was on it for three to four months. He tried to wean down on the methadone a couple of different times, but failed. He has been intermittently using heroin. He says one of the big problems is that he lives in a household full of drug users and he could not get away from it. All that changed now that he is living with his mom. The last time he did heroin was about seven to eight days ago. He has not had any methadone in about a week either. He is coming in today specifically requesting methadone. He also admits to being depressed. He is sad a lot and down. He does not have much energy. He does not have the enthusiasm. He denies any suicidal or homicidal ideations at the present time. I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms. His past medical history is significant for no medical problems. Surgical history, he voluntarily donated his left kidney. Family and social history were reviewed per the nursing notes. His allergies are no known drug allergies. Medications, he takes no medications regularly.,OBJECTIVE: , His weight is 164 pounds, blood pressure 108/60, pulse 88, respirations 16, and temperature was not taken. General: He is nontoxic and in no acute distress. Psychiatric: Alert and oriented times 3. Skin: I examined his upper extremities. He showed me his injection sites. I can see marks, but they seem to be healing up nicely. I do not see any evidence of cellulitis. There is no evidence of necrotizing fasciitis.,ASSESSMENT: , Substance abuse.,PLAN: , I had a long talk with the patient and his mom. I am not prescribing him any narcotics or controlled substances. I am not in the practice of trading one addiction for another. It has been one week without any sort of drugs at all. I do not think he needs weaning. I think right now it is mostly psychological, although there still could be some residual physical addiction. However, once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time. I do believe that his depression needs to be treated. I gave him fluoxetine 20 mg one tablet daily. I discussed the side effects in detail. I did also warn him that all antidepressant medications carry an increased risk of suicide. If he should start to feel any of these symptoms, he should call #911 or go to the emergency room immediately. If he has any problems or side effects, he was also directed to call me here at the office. After-hours, he can go to the emergency room or call #911. I am going to see him back in three weeks for the depression. I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group. We are unable to make a referral for him to do that. He has to call on his own. He has no insurance. However, I think fluoxetine is very affordable. He can get it for $4 per month at Wal-Mart. His mom is going to keep an eye on him as well. He is going to be staying there. It sounds like he is looking for a job. | soap / chart / progress notes, addicted to drugs, substance abuse, abuse, heroin, methadone |
1,303 | The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. | SOAP / Chart / Progress Notes | SOAP - Shortness of Breath | SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 78 and blood pressure 130/60.,LUNGS: Clear.,HEART: A soft systolic murmur in the aortic area.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema.,IMPRESSION:,1. Status shortness of breath responding well to medical management.,2. Atrial fibrillation, chronic, on anticoagulation.,3. Aortic stenosis.,RECOMMENDATIONS:,1. Continue medications as above.,2. The patient would like to follow with her cardiologist regarding aortic stenosis. She may need a surgical intervention in this regard, which I explained to her. The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back. | soap / chart / progress notes, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr, |
1,304 | She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet. | SOAP / Chart / Progress Notes | SOAP - Cholecystitis | SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS: Clear to auscultation. No wheezes, rales, or rhonchi.,HEART: Regular rhythm and rate.,ABDOMEN: Soft, less tender.,LABORATORY DATA:, Her white count continues to come down. Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000. We have ordered type and cross for 2 units of packed red blood cells. If it drops below 25, she will receive a transfusion. Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7. Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:, She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count. | soap / chart / progress notes, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis |
1,305 | Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. | SOAP / Chart / Progress Notes | SOAP - Lung Mass | SUBJECTIVE:, The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. The patient is doing fairly well. This afternoon, she called me because heart rate was in the range of 120 to 140. The patient is lying down. She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:, History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1. Cardizem, which is changed to 60 mg p.o. t.i.d.,2. Digoxin 0.25 mg daily.,3. Coumadin, adjusted dose.,4. Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 122 and blood pressure 102/68.,LUNGS: Air entry decreased.,HEART: PMI is displaced. S1 and S2 are irregular.,ABDOMEN: Soft and nontender.,IMPRESSION:,1. Pulmonary disorder with lung mass.,2. Pleural effusion.,3. Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1. From cardiac standpoint, follow with pulmonary treatment.,2. The patient has an INR of 2.09. She is on anticoagulation. Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above. | soap / chart / progress notes, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation, |
1,306 | Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected. | SOAP / Chart / Progress Notes | SOAP - Numbness & Tingling | SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16. General: The patient is nontoxic and in no acute distress. Musculoskeletal: The right hand was examined. It appears to be within normal limits and the appearance is similar to the left hand. She has good and equal grip strength noted bilaterally. She has negative Tinel's bilaterally. She has a positive Phalen's test. The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT: ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. I suspect carpal tunnel syndrome.,PLAN: ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint. We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time. She is going to let me know. While she is here, I am going to also get her the blood test she needs for her diabetes. I am noting that her blood pressure is elevated, but improved from the last visit. I also noticed that she has lost a lot of weight. She is working on diet and exercise and she is doing a great job. Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve. | soap / chart / progress notes, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling |
1,307 | MRI demonstrated right contrast-enhancing temporal mass. | SOAP / Chart / Progress Notes | SOAP - Temporal Mass | SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass. Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma. ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15. Cranial nerves II to XII are grossly intact. Motor exam demonstrates 5/5 strength in all four extremities. Sensation is intact to light touch, pain, temperature, and proprioception. Cerebellar exam is intact. Gait is normal and tandem on heels and toes. Speech is appropriate. Judgment is intact. Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass. Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme. We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing. Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma. The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor. He agrees that he will be n.p.o. after mid night on Wednesday night. He is sent for preoperative assessment with the Anesthesiology tomorrow morning. He has undergone vocational rehab assessment. | soap / chart / progress notes, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE |
1,308 | Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial. | SOAP / Chart / Progress Notes | Sleep Study Followup | REASON FOR VISIT:, This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue. She also complained of nocturnal choking episodes that have since abated over the past several months. In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results.,The patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m. She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night. She reports tossing and turning throughout the night and awakening with the sheets in disarray. She reports that her sleep was much better quality in the sleep laboratory as compared to home. When she awakens, she might have a dull headache and feels tired in the morning. Her daughter reports that she has heard the patient talking during sleep and snoring. There are no apneic episodes. The patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks.,During the daytime, the patient reports spending a lot of sedentary time reading and watching TV. She routinely dozes off during these sedentary activities. She also might nap between 2.00 and 3.00 p.m., and nods off in the evening hours.,The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner.,She reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago. Since that time, her weight is down by approximately 30 pounds.,The patient is managed in Outpatient Psychiatry and at her Maintenance Clinic. She takes methadone, trazodone, and Seroquel.,PAST MEDICAL HISTORY:,1. Depression.,2. Hepatitis C.,3. Hypertension.,4. Inhaled and intravenous drug abuse history.,The patient has a history of smoking two packs per day of cigarettes for approximately 25 pounds. She also has a history of recurrent atypical chest pain for which she has been evaluated.,FAMILY HISTORY: , As previously documented.,SOCIAL HISTORY: ,The patient has a history of inhalation on intravenous drug abuse. She is currently on methadone maintenance. She is being followed in Psychiatry for depression and substance abuse issues. She lives with a room-mate.,REVIEW OF SYSTEMS:, Not contributory.,MEDICATIONS: , Current medications include the following:,1. Methadone 110 mg by mouth every day.,2. Paxil 60 mg by mouth every day.,3. Trazodone 30 mg by mouth nightly.,4. Seroquel 20 mg by mouth nightly.,5. Avalide (irbesartan) and hydrochlorothiazide.,6. Albuterol and Flovent inhalers two puffs by mouth twice a day.,7. Atrovent as needed.,FINDINGS: , Vital Signs: Blood pressure 126/84, pulse 67, respiratory rate 18, weight 232 pounds, height 5 feet 8 inches, temperature 97.4 degrees, SaO2 is 99 percent on room air at rest. HEENT: Sclerae anicteric. Conjunctivae pink. Extraocular movements are intact. Pupils are equal, round, and reactive to light. The nasal passages show deviation in the nasal septum to the right. There is a slight bloody exudate at the right naris. Some nasal mucosal edema was noted with serous exudate bilaterally. The jaw is not foreshortened. The tongue is not large. Mallampati airway score was 3. The oropharynx was not shallow. There is no pharyngeal mucosa hypertrophy. No tonsillar tissue noted. The tongue is not large. Neck is supple. Thyroid without nodules or masses. Carotid upstrokes normal. No bruits. No jugular venous distention. Chest is clear to auscultation and percussion. No wheezing, rales, rhonchi or adventitious sounds. No prolongation of the expiratory phase. Cardiac: PMI not palpable. Regular rate and rhythm. S1 and S2 normal. No murmurs or gallops. Abdomen: Nontender. Bowel sounds normal. No liver or spleen palpable. Extremities: No clubbing or cyanosis. There is 1+ pretibial edema. Pulses are 2+ in upper and lower extremities. Neurologic: Grossly nonfocal.,LABORATORIES:, Pulmonary function studies reportedly show a mild restrictive ventilatory defect without obstruction. Diffusing capacity is well preserved.,An overnight sleep study was performed on this patient at the end of 02/07. At that time, she reported that her sleep was better in the laboratories compared to home. She slept for a total sleep time of 398 minutes out of 432 minutes in bed (sleep proficiency 92 percent). She fell asleep in the middle of latency of less than 1 minute. She woke up after sleep onset of 34 minutes. She had stage I sleep that was some elevated at 28 percent of total sleep time, and stage I sleep is predominantly evident in the lateral portion of the night. The remainders were stage II at 69 percent, stage III and IV at 3 percent of total sleep time.,The patient had no REM sleep.,The patient had no periodic limb movements during sleep.,The patient had no significant sleep-disordered breathing during non-REM sleep with less than one episode per hour. Oxyhemoglobin saturation remained in the low to mid 90s throughout the night.,Intermittent inspiratory flow limitation compatible with snoring was observed during non-REM sleep.,ASSESSMENT AND PLAN: , This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,Regarding the etiology of difficulty in initiating and maintaining sleep, the patient has a component of psychophysiologic insomnia, based on reports of better sleep in the laboratory as compared to home. In addition, nontrivial smoking in the home setting may be contributing significantly to sleep disruption.,Regarding her daytime sleepiness, the patient is taking a number of long-acting central nervous system acting medications to sedate her and can produce a lasting sedation throughout the daytime. These include trazodone, Seroquel, and methadone. Of these medications, the methadone is clearly indicative, given the history of substance abuse. It would be desirable to reduce or discontinue trazodone and then perhaps consider doing the same with Seroquel. I brought this possibility up with the patient, and I asked her to discuss this further with her psychiatrist.,Finally, to help mitigate sleep disruption at night, I have provided her with tips for sleep hygiene. These include bedtime rituals, stimulus control therapy, and sleep restriction as well as avoidance of nicotine in the evening hours. | null |
1,309 | The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. | SOAP / Chart / Progress Notes | Shortness Of Breath - Progress Note | She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications. She states that the methadone did not work for her. She was "immune" to oxycodone. She had been on tramadol before and was placed back on that. There was some question that this may have been causing some dizziness. She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon. He had a box of her pain medications. It is unclear whether she took a bunch of these or precisely what happened. I was contacted that she was less responsive. She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain. The nurse found her and was unable to arouse her at this point. There was a concern that she had taken some medications from home. She was given Narcan and appeared to come around some. Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m. Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity. With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted. A chest x-ray was obtained at this time. An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU. We will continue the IV Zosyn. Respiratory protocol with respiratory management. Continue alprazolam p.r.n., but avoid if she appears sedated. We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being. I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. At this juncture, she does not appear to need an intubation. Pending chest x-ray, she may require additional IV furosemide. | soap / chart / progress notes, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE |
1,310 | Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. | SOAP / Chart / Progress Notes | Sleep Apnea | REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure. He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night. Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask. The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays. On weekends, he might sleep until 8 to 9 a.m. On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP. He denies much tossing and turning and does not awaken with the sheets in disarray. He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore. He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m. He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina. He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS: ,Vital signs: Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories: The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea. I have recommended the patient continue CPAP indefinitely. He will be sending me his smart card for downloading to determine his CPAP usage pattern. In addition, he will continue efforts to maintain his weight at current levels or below. Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea. I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction. He will be returning for routine followup in 6 months. | soap / chart / progress notes, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep, |
1,311 | Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression. | SOAP / Chart / Progress Notes | Refractory Hypertension - Followup | PROBLEM LIST:,1. Refractory hypertension, much improved.,2. History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3. History of GI bleed in 1995.,4. History of depression.,HISTORY OF PRESENT ILLNESS:, This is a return visit to the renal clinic for this patient. She is an 85-year-old woman with history as noted above. Her last visit was approximately four months ago. Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously. She is not reporting any untoward side effect. She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. She has no orthopnea. Her exercise capacity is about the same. The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. No history of extremity pain.,CURRENT MEDICATIONS:,1. Triamterene/hydrochlorothiazide 37.5/25 mg.,2. Norvasc 10 mg daily.,3. Atenolol 50 mg a day.,4. Atacand 32 mg a day.,5. Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. THORAX: Revealed lungs that are clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3. I could not hear murmur today. ABDOMEN: Above plane, but nontender. EXTREMITIES: Revealed no edema.,ASSESSMENT:, This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us. In the meantime, we will discharge her from our practice. Should there be confusion or difficulty getting in the senior center, we can always see her back in followup | soap / chart / progress notes, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia |
1,312 | A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis. | SOAP / Chart / Progress Notes | Sexual Dysfunction - Chart Note | SUBJECTIVE:, The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction. Patient reports that he would like to try Cialis to see if it will improve his erectile performance. Patient states that he did a quiz on-line at the Cialis web site and did not score in the normal range, so he thought he should come in. Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem. In discussing with me directly, patient primarily expresses that he would like to have his erections last longer. However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration. However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse. Patient has no significant past medical history. He has never had any previous testicular infections. He denies any history of injuries to the groin and he has never been told that he has a hernia.,CURRENT MEDICATIONS:, None.,ALLERGIES: , No drug allergies.,SOCIAL: , Only occasionally drinks alcohol and he is a nonsmoker. He currently is working as a nurse aid, second shift, at a nursing home. He states that he did not enroll in Wichita State this semester. Stating he just was tired and wanted to take some time off. He states he is in a relationship with one partner and denies any specific stress in the relationship.,OBJECTIVE:,General: He appears in no distress.,Vital Signs: Blood pressure: With large cuff is 120/90.,Lungs: Clear to auscultation.,Cardiovascular: Normal S1-S2 without murmur.,Abdomen: Soft, nontender. Femoral pulses are 2+.,GU: Testicles descended bilaterally. No evidence of masses. No evidence of inguinal hernias.,ASSESSMENT:, Sexual dysfunction.,PLAN:, We will check a free and total testosterone level as he does note some diminished desire. He was given a sample of Cialis 10 mg with instructions on usage and a prescription for that if that is successful. He will follow up here p.r.n. Lastly, I did give him a blood pressure recording card, as his blood pressure is borderline today. He will have that checked weekly at his workplace and follow up if they remain elevated. | soap / chart / progress notes, cialis, able to maintain, erectile, sexual activity, sexual dysfunction, blood pressure, maintain, dysfunction, erections, sexual |
1,313 | Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine. | SOAP / Chart / Progress Notes | Rheumatology Progress Note | SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:, The patient is alert and oriented. General physical exam is unremarkable. Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion. Hand examination is unremarkable today. The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:, Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:, We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine. The posterior approach was chosen under sterile conditions. The patient tolerated both procedures well. I will obtain CBC and urinalysis today. If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D. | soap / chart / progress notes, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected, |
1,314 | Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. | SOAP / Chart / Progress Notes | Pulmonary Medicine Clinic Followup | SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains.,CURRENT MEDICATIONS:, The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:, Erythromycin.,REVIEW OF SYSTEMS:, Significant for problems with agitated depression. Her respiratory status is unchanged as noted above.,EXAMINATION:,General: The patient is in no acute distress.,Vital signs: Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT: Nasal mucosa was mild-to-moderately erythematous and edematous. Oropharynx was clear.,Neck: Supple without palpable lymphadenopathy.,Chest: Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular: Distant heart tones. Regular rate and rhythm.,Abdomen: Soft and nontender.,Extremities: Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1. Chronic obstructive pulmonary disease/emphysema, severe but stable.,2. Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3. History of depression and schizophrenia.,PLAN:, At this point, I have recommended that she continue current respiratory medicine. I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading. I have recommended that she use it with activity and at night. I spoke with her about her living situation. Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment. Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be. | soap / chart / progress notes, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary, |
1,315 | Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis. | SOAP / Chart / Progress Notes | Rotator Cuff Tear | REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy. She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07. At our last visit, I only had a report of her prior cervical spine MRI. I did not have any recent images. I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged. She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist. She has some associated minimal weakness described in detail in our prior office note. No significant right upper extremity symptoms. No bowel, bladder dysfunction. No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities. Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact. Biceps and brachioradialis reflexes are 1 plus. Hoffmann sign normal bilaterally. Motor strength is 5 out of 5 in all muscle groups in lower extremities. Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed. It is relatively limited study due to artifact. He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change. There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery. With regard to the radiculopathy, I believe this can be treated non-operatively to begin with. I am referring her for consideration of cervical epidural steroid injections. The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks. | soap / chart / progress notes, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical, |
1,316 | A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall. | SOAP / Chart / Progress Notes | Recheck of ADHD Meds | SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.,PAST HISTORY:, Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:, He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:, Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:, He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay. Review of systems is otherwise negative.,OBJECTIVE:, Weight is 46.5 pounds, which is down just a little bit from his appointment last month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room. Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:, At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:, Discussed with mother two options. Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose. As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer. So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Mother is to watch his diet. We would like to recheck his weight if he is doing very well, in two months. But if there are any problems, especially in the morning then we would do the Ritalin LA. Mother understands and will call if there are problems. Approximately 25 minutes spent with patient, all in discussion. | soap / chart / progress notes, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall, |
1,317 | Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. | SOAP / Chart / Progress Notes | Pulmonary - Followup Note | SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort. She denies any problems with cough or sputum production. No fevers or chills. Recently, she has had a bit more problems with fatigue. For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:, Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily. She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:, Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:, Noncontributory except as outlined above.,EXAMINATION:,General: The patient was in no acute distress.,Vital signs: Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT: Nasal mucosa was mild-to-moderately erythematous and edematous. Oropharynx was clear.,Neck: Supple without palpable lymphadenopathy.,Chest: Chest demonstrates decreased breath sounds, but clear.,Cardiovascular: Regular rate and rhythm.,Abdomen: Soft and nontender.,Extremities: Without edema. No skin lesions.,O2 saturation was checked at rest. On room air it was 96% and on ambulation it varied between 94% and 96%. Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis. She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1. Lupus with mild pneumonitis.,2. Respiratory status is stable.,3. Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:, At this time, I have recommended to continue her current medications. We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan. At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control. | soap / chart / progress notes, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary, |
1,318 | A 16-year-old male with Q-fever endocarditis. | SOAP / Chart / Progress Notes | Q-Fever Endocarditis | HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.,NECK: Supple without adenopathy.,CHEST: Clear including the sternal wound.,CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU: Deferred.,EXTREMITIES: Examination of extremities reveals no embolic phenomenon.,SKIN: Free of lesions.,NEUROLOGIC: Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN: ,1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.,2. Repeat Q-fever serology.,3. Comprehensive metabolic panel and CBC.,4. Return to clinic in 4 weeks.,5. Clotting times are being followed by Dr. X. | soap / chart / progress notes, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever, |
1,319 | Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 3 | PHYSICAL EXAMINATION: , The patient is a 63-year-old executive who was seen by his physician for a company physical. He stated that he was in excellent health and led an active life. His physical examination was normal for a man of his age. Chest x-ray and chemical screening blood work were within normal limits. His PSA was elevated.,IMAGING:,Chest x-ray: Normal.,CT scan of abdomen and pelvis: No abnormalities.,LABORATORY:, PSA 14.6.,PROCEDURES: , Ultrasound guided sextant biopsy of prostate: Digital rectal exam performed at the time of the biopsy showed a 1+ enlarged prostate with normal seminal vesicles.,PATHOLOGY: ,Prostate biopsy: Left apex: adenocarcinoma, moderately differentiated, Gleason's score 3 + 4 = 7/10. Maximum linear extent in apex of tumor was 6 mm. Left mid region prostate: moderately differentiated adenocarcinoma, Gleason's 3 + 2 = 5/10. Left base, right apex, and right mid-region and right base: negative for carcinoma.,TREATMENT:, The patient opted for low dose rate interstitial prostatic implants of I-125. It was performed as an outpatient on 8/10. | soap / chart / progress notes, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma |
1,320 | Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 2 | PHYSICAL EXAMINATION:, This 71-year-old man went to his primary care physician for a routine physical. His only complaints were nocturia times two and a gradual "slowing down" feeling. The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, R>L. PSA was elevated. The differential diagnosis for the visit was abnormal prostate, suggestive of CA.,IMAGING: ,CT pelvis: Irregular indentation of bladder. Seminal vesicles enlarged. Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus. Impression: prostatic malignancy with extracapsular extension and probable regional node metastasis.,Bone scan: Negative for distant metastasis.,LABORATORY:, PSA 32.1,PROCEDURES:, Transrectal needle biopsy of prostate. Pelvic lymphadenectomy and radical prostatectomy.,PATHOLOGY: ,Prostate biopsy: Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,Lymphadenectomy and prostatectomy: Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa. Therefore, the radical prostatectomy was canceled. ,Final pathology diagnosis: Pelvic lymphadenectomy; left obturator fossa, single negative lymph node. Right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes. Largest involved node 1.5 cm.,TREATMENT: , Patient began external beam radiation therapy to the pelvis. | soap / chart / progress notes, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma |
1,321 | A 65-year-old man with chronic prostatitis returns for recheck. | SOAP / Chart / Progress Notes | Prostatitis - Recheck | SUBJECTIVE:, The patient is a 65-year-old man with chronic prostatitis who returns for recheck. He follow with Dr. XYZ about every three to four months. His last appointment was in May 2004. Has had decreased libido since he has been on Proscar. He had tried Viagra with some improvement. He has not had any urinary tract infection since he has been on Proscar. Has nocturia x 3 to 4.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: ,Soon after birth for treatment of an inperforated anus and curvature of the penis. At the age of 70 had another penile operation. At the age of 27 and 28 he had repeat operations to correct this. He did have complications of deep vein thrombosis and pulmonary embolism with one of those operations. He has had procedures in the past for hypospadias, underwent an operation in 1988 to remove some tissue block in the anus. In January of 1991 underwent cystoscopy. He was hospitalized in 1970 for treatment of urinary tract infection. In 2001, left rotator cuff repair with acromioplasty and distal clavicle resection. In 2001, colonoscopy that was normal. In 2001, prostate biopsy that showed chronic prostatitis. In 2003, left inguinal hernia repair with MESH.,MEDICATIONS:, Bactrim DS one pill a day, Proscar 5 mg a day, Flomax 0.4 mg daily. He also uses Metamucil four times daily and stool softeners for bedtime.,ALLERGIES:, Cipro.,FAMILY HISTORY:, Father died from CA at the age of 79. Mother died from postoperative infection at the age of 81. Brother died from pancreatitis at the age of 40 and had a prior history of mental illness. Father also had a prior history of lung cancer. Mother had a history of breast cancer. Father also had glaucoma. He does not have any living siblings. Friend died a year and half ago.,PERSONAL HISTORY:, Negative for use of alcohol or tobacco. He is a professor at College and teaches history and bible.,REVIEW OF SYSTEMS:,Eyes, nose and throat: Wears eye glasses. Has had some gradual decreased hearing ability.,Pulmonary: Denies difficulty with cough or sputum production or hemoptysis.,Cardiac: Denies palpitations, chest pain, orthopnea, nocturnal dyspnea, or edema.,Gastrointestinal: Has had difficulty with constipation. He denies any positive stools. Denies peptic ulcer disease. Denies reflux or melena.,Genitourinary: As mentioned previously.,Neurologic: Without symptoms.,Bones and Joints: He has had occasional back pain.,Hematologic: Occasionally has had some soreness in the right axillary region, but has not had known lymphadenopathy.,Endocrine: He has not had a history of hypercholesterolemia or diabetes.,Dermatologic: Without symptoms.,Immunization: He had pneumococcal vaccination about three years ago. Had an adult DT immunization five years ago.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 202.8 pounds. Blood pressure: 126/72. Pulse: 60. Temperature: 96.8 degrees.,General Appearance: He is a middle-aged man who is not in any acute distress.,HEENT: Eyes: Pupils are equally regular, round and reactive to light. Extraocular movements are intact without nystagmus. Visual fields were full to direct confrontation. Funduscopic exam reveals middle size disc with sharp margins. Ears: Tympanic membranes are clear. Mouth: No oral mucosal lesions are seen.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1 and S2 without gallops or rubs.,Abdomen: Without tenderness or masses to palpation.,Genitorectal exam: Not repeated since these have been performed recently by Dr. Tandoc.,Extremities: Without edema.,Neurologic: Reflexes are +2 and symmetric throughout. Babinski is negative and sensation is intact. Cranial nerves are intact without localizing signs. Cerebellar tension is normal.,IMPRESSION/PLAN:,1. Chronic prostatitis. He has been stable in this regard.,2. Constipation. He is encouraged to continue with his present measures. Additionally, a TSH level will be obtained.,3. Erectile dysfunction. Testosterone level and comprehensive metabolic profile will be obtained.,4. Anemia. CBC will be rechecked. Additional stools for occult blood will be rechecked. | null |
1,322 | Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 4 | PHYSICAL EXAMINATION:, Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0. All other systems were normal.,PROCEDURES: ,Sextant biopsy of the prostate.,Radical prostatectomy: Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy: Right lobe, negative. Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy: Negative lymph nodes. Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right. Tumor overall involved less than 5% of the tissue. Surgical margin was reported and involved at the apex. The capsule and seminal vesicles were free.,DISCHARGE NOTE:, Patient has made good post-op recovery other than mild urgency incontinence. His post-op PSA is 0.1 mg/ml. | soap / chart / progress notes, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate, |
1,323 | Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 1 | HISTORY:, This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction. After catheterization, the patient underwent cystoscopy on 4/13. On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved. Final diagnosis was adenocarcinoma of the prostate. Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:, None,PROCEDURES:,Cystoscopy: Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate: 45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue. | soap / chart / progress notes, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma, |
1,324 | The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA. | SOAP / Chart / Progress Notes | Prostate Fossa Irradiation - Followup | HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. His urinary function had been stable until 2 days ago. Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks). His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional. The bowel function is stable with occasional irritative hemorrhoidal symptoms. He has had no hematochezia. The PSA has been slowly rising in recent months. This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days. No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100. He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds. (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1. NyQuil.,2. Timolol eye drops.,3. Aspirin.,4. Advil.,5. Zinc.,PHYSICAL EXAMINATION,GENERAL: Pleasant, well-developed, gentleman in no acute distress. Weight is 197 pounds.,HEENT: Sclerae and conjunctivae are clear. Extraocular movement are intact. Hearing is grossly intact. The oral cavity is without thrush. There is minor pharyngitis.,LYMPH NODES: No palpable lymphadenopathy.,SKELETAL: No focal skeletal tenderness.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION: There are external hemorrhoids. The prostate fossa is flat without suspicious nodularity. There is no blood on the examining glove.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: Without focal deficit.,IMPRESSION:, Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient. He understands the probability that there may be residual cancer although the location is unknown. For now there is no good evidence that early management affects the ultimate prognosis. Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA. I also suggested that he reestablish contact with Dr. X at his convenience. | null |
1,325 | Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis. | SOAP / Chart / Progress Notes | Progress Note - Supraglottitis | HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED: ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver. No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION: ,1. Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2. Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3. Hypercholesterolemia.,4. History of anxiety.,5. History of coronary artery disease.,6. Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X. Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation. I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern. | soap / chart / progress notes, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis |
1,326 | Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. | SOAP / Chart / Progress Notes | Progress Note - Liver Cirrhosis | HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. The patient at that time stated that he had established diagnosis of liver cirrhosis. Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody. Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion. He spent 3 days in the hospital. He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient. From the patient's report he was diagnosed with some kind of viral infection. At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS: Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions.,NECK: Supple. No lymphadenopathy. No thyromegaly.,LUNGS: Clear to auscultation and percussion bilateral.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.,ABDOMEN: Not tender, not distended. Splenomegaly about 4 cm under the costal margin. No hepatomegaly. Bowel sounds present.,MUSCULOSKELETAL: No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC: Nonfocal. No asterixis. No costovertebral tenderness.,PSYCHE: The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63. His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53. We do not have any other results back. No hepatitis panels. No alpha-fetoprotein level. The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:, The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1. Epigastric pain. The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time. In the office twice the patient did not have any abdominal pain on physical exam. His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously. He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2. End-stage liver disease. Of course, we need to find out the cause of the liver cirrhosis. We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before. We do not have any information of any type of investigation in the past. Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X. The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result. It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level. We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver. We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B. Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C. The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also. We will need to look for nuclear antibody if it is not done before. PSC is extremely unlikely but possible. Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not. Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem. On his end-stage liver disease we already know that he had low platelet count splenomegaly. We know that his bilirubin is elevated and albumin is very low. I suspect that at the time of admission to the hospital the patient presented with encephalopathy. We do not know if INR was checked to look for coagulopathy. The patient had an EGD in 2005 as well as colonoscopy in Silver City. We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily. The patient tolerated it well; no diarrhea at this point in time. I also recommended for him to contact his primary care physician for increased dose of opiates for him. As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal. The patient got a prescription for 10 mg pills. He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58. The patient was educated how to use Inderal and he was explained why we decided to use this medication. The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues. The patient was provided information that his protein intake is supposed to be about 25 g per day. He was advised not to over-eat protein and advised not to starve. He also was advised to stay away from alcohol. His next visit is in 2 weeks with all results available. | soap / chart / progress notes, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis, |
1,327 | Patient developed iron deficiency anemia and had blood in his stool. | SOAP / Chart / Progress Notes | Progress Note - Iron Deficiency Anemia | HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool. The patient also has chronic diarrhea. His anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have hemoglobin of 9 and MCV 65. The patient also had multiple episodes of dark blood and bright blood in the stool for the last 5 months on and off. Last colonoscopy was performed by Dr. X in Las Cruces 3 years ago. At that time the patient had polyps removed from the colon, all of them were hyperplastic in nature. The patient also was diagnosed with lymphocytic colitis. He was not treated for diarrhea for more than 3 years.,PAST MEDICAL HISTORY: , Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking.,MEDICATIONS: , Iron supplement.,ALLERGIES: ,The patient has no known drug allergies.,FAMILY HISTORY:, Includes coronary artery disease, hypertension. Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.,SOCIAL HISTORY:, The patient smoked 1-1/2 packs for more than 40 years. He consumes 6 beers per day. He denies any drug use.,REVIEW OF SYSTEMS: , The patient has no night sweats. Good appetite. Stable weight. No chills, no fevers. No visual problems. No hearing problems. The patient denies any difficulty swallowing, any nausea or vomiting, any burning sensation in the esophagus. The patient has had chronic diarrhea for more than 3 years. His stool is daily, 1-2 times per day and very loose. He also admitted to have dark and bright blood in the stool on and off for more than 5 months. Respiratory review of systems was significant for COPD. The patient is not on oxygen and his COPD is mild. He denies any neurological problems, psychiatric problems, endocrine problems, hematological problems, lymphatic problems, immunological problems, allergy problems. The patient had recent episode of significant skin itching all over the body.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight 221 pounds. Height 6 feet 1 inch. Blood pressure 124/62, heart rate 87, temperature 98.4, saturation 98%. Pain is 0/10.,GENERAL: Well-developed, well-nourished, normal asthenic. Good attention to grooming.,HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions. Good dentition.,NECK: Supple. No lymphadenopathy. No thyromegaly.,LUNGS: Clear to auscultation and percussion bilaterally. No wheezing, no rhonchi, no crackles.,CARDIOVASCULAR: Regular rate and rhythm. The patient had 2/6 systolic ejection murmur on aortic valve projected to carotid artery. No rubs, no gallops. No JVD. Peripheral pulses 2+ in both radialis and both dorsalis pedis bilaterally.,ABDOMEN: No masses, no tenderness. No distention. No hepatosplenomegaly. Bowel sounds present.,RECTAL: Good sphincter tone. No palpable nodules. No masses. No blood. Dark stool, the patient is taking iron. Test was sent for occult blood test.,BACK: No costovertebral tenderness bilaterally.,LYMPHATICS: The patient had no neck, axial, groin or supraclavicular lymphadenopathy on exam.,MUSCULOSKELETAL: The patient had good, stable gait. No clubbing, no cyanosis, no pitting edema. Full range of motion. No joint deformities.,SKIN: Clear of rashes and lesions. No ulcers.,NEUROLOGICAL: Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both knees and both biceps. Babinski negative bilaterally. Good control of bowel and urinary bladder. No local weakness.,PSYCHIATRIC: The patient had good judgment and insight. Oriented x4. Good recent and remote memory. Appropriate mood and affect.,ASSESSMENT & PLAN: ,The patient is a 55-year-old gentleman with iron deficiency anemia, blood in the stool. The patient needs evaluation for source of bleeding with a colonoscopy. The patient was explained rationale, risks, benefits, and alternatives of the procedure. He accepted the recommendation. Colonoscopy scheduled. The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality. The patient had multiple tests from a previous examination. One of the pathology reports from Dr. X from 2003 showed lymphocytic microscopic colitis, hyperplastic polyps. Reviewed also multiple lab tests including CBC, CMP. The patient had Coombs' test negative. His reticulocyte count is 2.41. His iron TIBC 514, serum iron 29, ferritin 7. He had no liver function test abnormality. PSA was in the normal range. The patient had x-ray which showed pulmonary hyperinflation and emphysema. The patient will be followed up with result of colonoscopy. | null |
1,328 | Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. | SOAP / Chart / Progress Notes | Polycythemia Rubra Vera | CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES: ,Penicillin.,REVIEW OF SYSTEMS: ,The patient's chief complaint is her weight. She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key. She has questions as to whether or not there would be any contra indications to her going on the diet. Otherwise, she feels great. She had family reunion in Iowa once in four days out there. She continues to volunteer Hospital and is walking and enjoying her summer. She denies any fevers, chills, or night sweats. She has some mild constipation problem but has had under control. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS: | soap / chart / progress notes, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia, |
1,329 | This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. | SOAP / Chart / Progress Notes | Postop Parathyroid Exploration & Parathyroidectomy | SUMMARY: ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. She put out 1175 mL of urine since surgery. Her incision looks good. IV site and extremities are unremarkable.,LABORATORY DATA: ,Her calcium level was 7.5 this morning. She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:, I will heparin lock her IV, advance her diet, and ambulate her. I have asked her to increase her prednisone when she goes home. She will double her regular dose for the next five days. I will advance her diet. I will continue to monitor her calcium levels throughout the day. If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow. She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill. Her final calcium dosage will be determined prior to discharge. I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems. | soap / chart / progress notes, parathyroid hyperplasia, parathyroid exploration, pth, hyperplasia, parathyroidectomy, parathyroidNOTE |
1,330 | Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. | SOAP / Chart / Progress Notes | Polycythemia Vera Followup | DIAGNOSIS:, Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped.,The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints.,3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems. | soap / chart / progress notes, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis, |
1,331 | Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. | SOAP / Chart / Progress Notes | Podiatry - Progress Note | SUBJECTIVE:, Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is currently doing no treatment for it. He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:, Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit. There is tenderness to palpation to the medial tubercle of the right foot. The pain is elicited along the medial arch as well. There are no open areas or signs of infection noted.,ASSESSMENT:, Plantar fascitis/heel spur syndrome, right foot.,PLAN:, The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. He was given a low dye strapping and a heel lift was placed in his right shoe. The patient will be seen back in approximately one month for further evaluation if necessary. He was told to call if anything should occur before that. The patient was told to continue with the good work on his diabetic control. | soap / chart / progress notes, progress note, plantar fascitis, podiatry, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel |
1,332 | Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy. | SOAP / Chart / Progress Notes | Posttransplant Lymphoproliferative Disorder | CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1. Posttransplant lymphoproliferative disorder.,2. Chronic renal insufficiency.,3. Squamous cell carcinoma of the skin.,4. Anemia secondary to chronic renal insufficiency and chemotherapy.,5. Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007. He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. He did not seek medical attention immediately. He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. He was discussed at the hematopathology conference. Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. First cycle of chemotherapy was complicated by sepsis despite growth factor support. He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date. He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well. His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy. He states he feels well. He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. He denies any tingling or numbness in his fingers. Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. There is mild pallor noted. There is no icterus, adenopathy or petechiae noted. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. Systolic flow murmur is best heard in the pulmonary area. ABDOMEN: Soft and nontender with no organomegaly. Renal transplant is noted in the right lower quadrant with a scar present. EXTREMITIES: Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1. Diffuse large B-cell lymphoma following transplantation. The patient is to receive his sixth and final cycle of chemotherapy today. PET scan has been ordered to be done within 2 weeks. He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2. Chronic renal insufficiency.,3. Anemia secondary to chronic renal failure and chemotherapy. He is to continue on his regimen of growth factor support.,4. Hypertension. This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. His CMP is pending from today.,5. Squamous cell carcinoma of the skin. The scalp is well healed. He still has an open wound on the right posterior aspect of his trunk. This has no active drainage, but it is yet to heal. This probably will heal by secondary intention once chemotherapy is finished. Prescription for prednisone as part of his chemotherapy has been given to him. | soap / chart / progress notes, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative, |
1,333 | A 44-year-old, 250-pound male presents with extreme pain in his left heel. | SOAP / Chart / Progress Notes | Plantar Fasciitis | S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old. He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face. He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet. He has redness of the right toes 2, 3 and 4. Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1. Plantar fasciitis., | soap / chart / progress notes, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar, |
1,334 | Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. | SOAP / Chart / Progress Notes | Physical Therapy - Outpatient Rehab | SUMMARY: ,The patient has attended physical therapy from 11/16/06 to 11/21/06. The patient has 3 call and cancels and 3 no shows. The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE: ,The patient states pain still significant, primarily 1st seen in the morning. The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that. The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more. The patient does feel like he is putting on more muscle girth as well. The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well.,OBJECTIVE: , Physical therapy has consisted of:,1. Pool therapy incorporating endurance and general lower and upper extremity strengthening.,2. Clinical setting incorporating core stabilization and general total body strengthening and muscle wasting.,3. The patient has just begun this, so it is on a very beginners level at this time.,ASSESSMENT, DONE ON 12/21/06,STRENGTH,Activities | null |
1,335 | Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her. | SOAP / Chart / Progress Notes | PAF - 6-Month Followup | REASON FOR VISIT:, Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:, No palpitations. No lightheadedness or presyncope. She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP: 112/74. PR: 70. WT: 223 pounds (up three pounds). Cardiac: Regular rate and rhythm with a 1/6 murmur at the upper sternal border. Chest: Nontender. Lungs: Clear. Abdomen: Moderately overweight. Extremities: Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1. Chest pain-Mild. Her EKG is mildly abnormal. Her last stress echo was in 2001. I am going to have her return for one just to make sure it is nothing serious. I suspect; however, that is more likely due to her weight and acid reflux. I gave her samples of Nexium.,2. Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3. PAF-Due to hypertension, hyperthyroidism and hypokalemia. Staying in sinus rhythm.,4. Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5. Dyslipidemia-Samples of Crestor given.,6. LVH.,7. Menometrorrhagia.,PLAN:,1. Return for stress echo.,2. Reduce the fluid intake to help with pedal edema.,3. Nexium trial. | soap / chart / progress notes, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial, |
1,336 | Pain management sample progress note. | SOAP / Chart / Progress Notes | Pain Management Progress Note | DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone. The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:, The patient is appropriate. She is well dressed and oriented x3. She still smells of some cigarette smoke. Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles. There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved. On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding. This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:, After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles. A total of 400 units of Botox is anticipated. The procedure is being scheduled. The patient's medications are refilled. She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria. | soap / chart / progress notes, progress note, management, muscle |
1,337 | Overactive bladder with microscopic hematuria. | SOAP / Chart / Progress Notes | Overactive Bladder | REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. The patient had been previously on Ditropan and did not do nearly as well. At this point, what we will try is a different medication. Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted. She has no other significant findings other than her overactive bladder, which had continued. At this juncture what I would like to do is try a different anticholinergic medication. She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan. We will start Sanctura XR and we will follow up as scheduled. Otherwise we will continue to follow her urinalysis over the next year or so. | soap / chart / progress notes, overactive bladder with microscopic hematuria, irritative voiding symptoms, anticholinergic, microscopic hematuria, overactive bladder, ditropan, microscopic, hematuria, bladder, overactive |
1,338 | The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day. | SOAP / Chart / Progress Notes | ORIF Facial Fractures - Followup | Mr. ABC was transferred to room 123 this afternoon. We discussed this with the nurses, and it was of course cleared by Dr. X. The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening. This will make it much easier for him to swallow. This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today. He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place. It is a size 8 Shiley nonfenestrated. He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing. Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary. | soap / chart / progress notes, fenestrated tube, nasal fracture, facial fractures, orif, tracheotomy, tube, fractures, |
1,339 | A 47-year-old white female presents with concern about possible spider bite to the left side of her neck. | SOAP / Chart / Progress Notes | Possible Spider Bite | SUBJECTIVE:, This 47-year-old white female presents with concern about possible spider bite to the left side of her neck. She is not aware of any specific injury. She noticed a little tenderness and redness on her left posterior shoulder about two days ago. It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck. She has had no fever. The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:, Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:, No known medicine allergies.,OBJECTIVE:,Vital Signs: Weight is 150 pounds. Blood pressure 122/82.,Extremities: Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter. In the center is a tiny mark which could certainly be an insect or spider bite. There is no eschar there, but just a tiny marking. There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:, Possible insect bite with lymphangitis.,PLAN:,1. Duricef 1 g daily for seven days.,2. Cold packs to the area.,3. Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4. Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas. I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only. | soap / chart / progress notes, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite, |
1,340 | Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak. | SOAP / Chart / Progress Notes | Poison Ivy - SOAP | SUBJECTIVE:, He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg. He said that it worked fairly well, although it seemed to still take awhile to get rid of it. He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals: Temperature is 99.2. His weight is 207 pounds.,Skin: Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:, Poison ivy. Plan would be Solu-Medrol 125 mg IM X 1. Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead. | soap / chart / progress notes, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison |
1,341 | Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture. | SOAP / Chart / Progress Notes | ORIF - Followup | REASON FOR VISIT:, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema. There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted. The patient had 3/5 strength in the EHL, FHL. He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee. It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee. I would like to really work on this as he has not had much up to this time. He should remain nonweightbearing. I would like to have him return in 2 weeks' time to assess his knee range of motion. He should not need x-rays at that time. | soap / chart / progress notes, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif, |
1,342 | Ophthalmology followup visit note. | SOAP / Chart / Progress Notes | Ophthalmology Progress Note - 2 | A fluorescein angiogram was ordered at today's visit to rule out macular edema. We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress. A copy of the angiogram is enclosed for your records. | soap / chart / progress notes, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, ophthalmology, lensesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. |
1,343 | Orthopedic progress note for follow up of osteoarthritis, knees. | SOAP / Chart / Progress Notes | Osteoarthritis - Progress Note | CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain: Localized to the bilateral knees right worse than left.,Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. ,Duration: Months.,Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. ,Hip Pain: None. ,Back pain: None. ,Radicular type pain: None. ,Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:, No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living. ,REVIEW OF SYSTEMS:, No change.,Constitutional: Good appetite and energy. No fever. No general complaints.,HEENT: No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP: No shortness of breath at rest or with exertion. No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum. No chest pain on exertion.,GI: | null |
1,344 | Ophthalmology followup visit note. | SOAP / Chart / Progress Notes | Ophthalmology Progress Note - 1 | She is stable at this time and does not require any intervention at today's visit. I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision. | soap / chart / progress notes, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, ophthalmology, acuitiesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. |
1,345 | MGUS. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS. | SOAP / Chart / Progress Notes | MGUS Followup | CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:, This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS.,Overall, he is doing well. Since I last saw him, he tells me that he has had onset of atrial fibrillation. He has now started going to the gym two times per week, and has lost over 10 pounds. He has a good energy level and his ECOG performance status is 0. He denies any fever, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax 0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES: ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. He is status post left inguinal hernia repair.,2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT: | null |
1,346 | Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis. | SOAP / Chart / Progress Notes | Nephrolithiasis - Progress Note | SUBJECTIVE:, The patient returns today for a followup. She was recently in the hospital and was found to be septic from nephrolithiasis. This was all treated. She did require a stent in the left ureter. Dr. XYZ took care of this. She had a stone, which was treated with lithotripsy. She is now back here for followup. I had written out all of her medications with their dose and schedule on a progress sheet. I had given her instructions regarding follow up here and follow with Dr. F. Unfortunately, that piece of paper was lost. Somehow between the hospital and home she lost it and has not been able to find it. She has no followup appointment with Dr. F. The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc. Later she apparently found the prescriptions and they were filled. She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take. She had no clue as to seeing Dr. XYZ again. She says she is still not feeling very well and feels somewhat sick like. She has no clue as to still having a ureteral stent. I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:, As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:, She says she is voiding okay. She denies fever, chills, or sweats.,OBJECTIVE:,General: She was able to get up on the table by herself although she is quite unstable.,Vital Signs: Blood pressure was okay at about 120/70 by me.,Neck: Supple.,Lungs: Clear.,Heart: Regular rate and rhythm.,Abdomen: Soft.,Extremities: There is no edema.,IMPRESSION:,1. Hypertension controlled.,2. Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3. Urinary incontinence.,4. Recent sepsis.,PLAN:,1. I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2. I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3. See me back here in two months.,4. I made no changes in her medications. | soap / chart / progress notes, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications, |
1,347 | A woman with end-stage peritoneal mesothelioma with multiple bowel perforations. | SOAP / Chart / Progress Notes | Mesothelioma - Chart Note | The patient's home regimen includes Duragesic patch at 125 mcg every 3 days. She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum. The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block. The patient's family and she will continue to think about these pain procedures and let us know if they are interested in either. For the moment, we will not make any further recommendations on her current medical management. We did ask Dr. X, a psychiatrist, who works for the Pain Service to come in and see Ms. A as anxiety is a large component of her suffering at this time., | soap / chart / progress notes, pleurodesis, abdominal pain, multiple bowel perforations, peritoneal mesothelioma, mesothelioma, peritonealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., |
1,348 | Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator. | SOAP / Chart / Progress Notes | Multiple Progress Notes | PROGRESS NOTES,4/16/01:,Patient in respiratory failure, on ventilator,Request airline placement,Airline tracing good,4/17/01:,S: Sedated, intubated in NAD,O: Lungs: Increased bibasilar crackles,A/P: Respiratory arrest, pneumonia, COPD exacerbation,Replete K+, continue IVABX, start TPN, decrease TV, review ABGs,4/18/01:,S: Sedated and intubated, one episode NSVT,O: ABGs: 7.38/67/86/97,4/19/01:,S: Sedated and intubated, scant blood material from NGT,A/P: 1) Respiratory arrest,2) Exacerbation COPD - gastro cath NG aspiration,4/20/01:,S: Intubated/sedated, w/ NAD,O: Pulmonary - Increase L. basilar inspiration,A/P: Pneumonia,Respiratory arrest,COPD exacerbation,New onset low grade fever,D/C NGT - suspect sensitivity,4/20/01:,O: Preliminary blood culture gram + cocci,Dr. A called w/ result, no orders left,Pt. afebrile, WBC increase to 20.2,ABGs improved from 4/20/01, pt. noted to have less secretions,Last night had 8 beat run V-Tach,4/21/01:,O: Chest x-rays reviewed - improvement in lower lobe infiltrate,Gram + cocci in blood,Sputum H. influen. gram neg.,4/22/01:,atient up in chair,Decrease ventilator support,Preliminary blood cultures - Staph coag neg 1 of 2,04/23/01:,S: Awake, alert in NAD,O: Temp 99.8,Blood cultures: Staph coag. Neg. 1 of 2,A/P: Pneumonia, respiratory arrest, COPD,Continue wearing tirals,4/24/01:,S: Awake and alert, +N, refused trach,If fails extubation, will allow for reintubation | null |
1,349 | Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.) | SOAP / Chart / Progress Notes | Multiple Medical Problems | SUBJECTIVE:, The patient was seen today by me at Nursing Home for her multiple medical problems. The nurses report that she has been confused at times, having incontinent stool in the sink one time but generally she does not do that poorly. She does have trouble walking which she attributes to weak legs. She fell a couple of months ago. Her eating has been fair. She has been losing weight a little bit. She denies diarrhea. She does complain of feeling listless and unambitious and would like to try some Ensure.,CURRENT MEDICATIONS:, Her meds are fairly extensive and include B12 1000 mg IM monthly, Digitek 250 p.o. every other day alternating with 125 mcg p.o. every other day, aspirin 81 mg daily, Theragran-M daily, Toprol XL 25 mg daily, vitamin B6 100 mg daily, Prevacid 30 mg daily, Oyster Shell calcium with D 500 mg t.i.d., Aricept 5 mg daily, Tylenol 650 mg q.4h. p.r.n., furosemide 20 mg daily p.r.n., and sublingual Nitro p.r.n., and alprazolam 0.25 mg p.r.n.,ALLERGIES:, Sulfa and trimethoprim.,OBJECTIVE:,General: She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs: Her age is 90. Temperature is 98.5 degrees. Blood pressure: 100/54. Pulse: 60. Respirations: 18. Weight was 132.6 about a week ago, which is down one pound from couple of months ago.,HEENT: Head was normocephalic.,Neck: Supple.,Lungs: Clear.,Heart: Regular rate and rhythm.,Abdomen: Soft, nontender without hepatosplenomegaly or mass.,Extremities: No calf tenderness or significant ankle edema x 2 in the lower extremities is noted.,Mental Status Exam: She was uncertain what season we are in. She thought we were almost in winter. She did know that today of the week was Friday. She seemed to recognize me.,ASSESSMENT:,1. Alzheimer’s dementia.,2. Gradual weight loss.,3. Fatigue.,4. B12 deficiency.,5. Osteoporosis.,6. Hypertension.,PLAN:, I ordered yearly digoxin levels. Increased her Aricept to 10 mg daily. She apparently does have intermittent atrial fibrillation as a reason for being on the digoxin. We will plan to recheck her in a couple of months. Ordered health supplement to be offered after each meal due to her weight loss. | soap / chart / progress notes, progress note, alzheimer’s dementia, b12 deficiency, fatigue, hypertension, osteoporosis, digoxin, incontinent stool, multiple medical problems, weak, weight loss, multiple, dementia, alzheimer’s, incontinent, |
1,350 | Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study. | SOAP / Chart / Progress Notes | Obesity Hypoventilation Syndrome | HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep.",MEDICATIONS: , Current medications are as previously noted. Changes include reduction in prednisone from 9 to 6 mg by mouth every morning. She continues to take Ativan 1 mg every six hours as needed. She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs: Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest. Chest is clear. Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used. She used it for greater than 4 hours per night on 67% of night surveyed. Her estimated apnea/hypopnea index was 3 per hour. Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy. She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%). Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour. Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%. During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1. Obesity hypoventilation syndrome. The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity. In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2. Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute. The breathing pattern is that of cluster or Biot's breathing throughout sleep. The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3. Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4. Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep. These will include, (1). Decrease in evening doses of MS Contin, (2). Modest weight loss of approximately 10 to 20 pounds, and (3). Instituting Automated Servo Ventilation via nasal mask. With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements. I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed. I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time. She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation. Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing. | soap / chart / progress notes, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity, |
1,351 | A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant. | SOAP / Chart / Progress Notes | Mantle Cell Lymphoma | PRINCIPAL DIAGNOSES:,1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3. Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4. Diabetes.,5. Bipolar disorder.,6. Chronic muscle aches.,7. Chronic lower extremity edema.,8. ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1. Paxil 40 mg once daily.,2. Cozaar.,3. Xanax 1 mg four times a day.,4. Prozac 20 mg a day.,5. Lasix 40 mg a day.,6. Potassium 10 mEq a day.,7. Mirapex two tablets every night.,8. Allegra 60 mg twice a day.,9. Avandamet 4/1000 mg daily.,10. Nexium 20 mg a day.,11. NovoLog 25/50.,REVIEW OF SYSTEMS:, Fatigue, occasional rectal bleeding, and obesity. Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. HEENT: Oral cavity, no mucositis. NECK: No nodes. AXILLA: No nodes. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: No palpable masses. Morbid obesity. EXTREMITIES: Mild lower extremity edema. SKIN: Mild dryness. CNS: Grossly intact.,LABORATORY DATA:, White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9. Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1. The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. He is without evidence of disease at the present time. Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2. He is slightly anemic, may be iron deficient. He has had recurrent rectal bleeding. I told him to take multivitamin with iron and see how that helps the anemia.,3. Regarding the hematochezia, he had an endoscopy. I reviewed the results from the previous endoscopy. It appears that he has polyps, but there is no evidence of graft versus host disease.,4. Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5. He is followed for his diabetes by his internist.,6. If he should have any fever or anything suggestive of infection, I advised him to call me. I will see him back in about 2 months from now. | null |
1,352 | Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. | SOAP / Chart / Progress Notes | Melena - ICU Followup | HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.,EYES: Conjunctivae are now pink.,ENT: Oropharynx is clear.,CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.,LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN: Soft and nontender with no organomegaly appreciated.,EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.,NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:, Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes. | soap / chart / progress notes, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding |
1,353 | Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. | SOAP / Chart / Progress Notes | Non-Hodgkin lymphoma Followup | CHIEF COMPLAINT:, Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy. In 1990, his CT scan showed retroperitoneal lymphadenopathy. Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP. In 1999, he was treated with m-BACOD. He also received radiation to his pelvis. On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma. His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well. He has a good energy level, his ECOG performance status is 0. He denies any fever, chills or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2. He had bilateral ureteral obstruction and is status post a stent placement. The obstruction was secondary to his pelvic radiation.,3. History of congestive heart failure.,4. History of schwannoma resection. It was resected from T12 to L1 in 1991.,5. He has chronic obstruction of his inferior vena cava.,6. Recurrent lower extremity cellulitis.,SOCIAL HISTORY: ,He has no tobacco use. No alcohol use. He is married. He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago. There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT: | null |
1,354 | Neurologic examination sample. | SOAP / Chart / Progress Notes | Neurologic Examination | NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. ,Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection. | soap / chart / progress notes, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE |
1,355 | Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax. | SOAP / Chart / Progress Notes | Lung Cancer Followup | CHIEF COMPLAINT:,1. Extensive stage small cell lung cancer.,2. Chemotherapy with carboplatin and etoposide.,3. Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment with carboplatin and etoposide. She completed her fifth cycle on 08/12/10. She has had ongoing back pain and was sent for a CT scan of the thorax. She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: ,The patient continues to have back pain some time she also take two pain pill. She received platelet transfusion the other day and reported mild fever. She denies any chills, night sweats, chest pain, or shortness of breath. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS: | soap / chart / progress notes, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer, |
1,356 | Patient is here to discuss possible open lung biopsy. | SOAP / Chart / Progress Notes | Lung Biopsy Discussion | CHART NOTE:, She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow. Dr. XYZ had seen her because of her complaints of shortness of breath. Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep. He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy. She was ready to go ahead with this and felt that it was important she find out why she is short of breath. She is very concerned about the findings on her CAT scan and pulmonary function test. She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal. However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function. And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time. After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy. In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed. I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those. And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it. I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests. And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy. But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her. She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing. We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time. I told her I would try to talk to her sister sometime in the next day or two. | soap / chart / progress notes, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., |
1,357 | A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle. | SOAP / Chart / Progress Notes | Leg Pain & Bone Pain | CHIEF COMPLAINT:, Leg pain.,HISTORY OF PRESENT ILLNESS:, This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionally. She has had a little bit of fever and nausea. She has noticed her blood sugars have been low. She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita. She has noticed her fasting blood sugars have been ranging from 100 to 120. Blood sugars one and a half hours after meals have been 185. She is coming in for a diabetic checkup in one month and wants lab prior to that time. She has been eating more meat recently and has not been on a diet for cholesterol.,CURRENT MEDICATIONS:, Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d., Maxzide 37/25 q.d., Protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d.,ALLERGIES:, Cipro, sulfa, Bactrim, and Demerol.,OBJECTIVE:,Vital Signs: Weight is 248 pounds which is a 12-pound drop from January. Blood pressure 120/70. Pulse 68.,General: This is a well-developed adult female, awake, alert, and in no acute distress.,HEENT: Oropharynx and HEENT are within normal limits.,Lungs: Clear.,Heart: Regular rhythm and rate.,Abdomen: Soft, nontender, and nondistended without organomegaly.,GU: Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.,Neurologic: Deep tendon reflexes are normal.,Extremities: Pulses in lower extremities are normal. Straight leg lifts are normal.,ASSESSMENT/PLAN:,1. Leg pain/bone pain, I am going to check her CMP. I think this possibly is a side effect from Lipitor. We will stop Lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time. Certainly if her pain improves might consider something like Crestor, which is more water soluble, which may cause less adverse effects. We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone.,2. Hypercholesterolemia, this is somewhat bothersome as she is a diabetic. Did discuss with her that we need to stick to the diet especially after going off of Lipitor. We will see how she does with her bone pain/leg pain off of Lipitor. If she has improvement may consider Crestor in one month. I am going to check her lipid panel and a CMP. Apparently, she is going to get this at a different site, Mapleridge in Wichita.,3. Type II diabetes. We will decrease her Glucovance because she is having frequent low blood sugars. Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms. I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment. | soap / chart / progress notes, cmp, hypercholesterolemia, leg pain, type ii diabetes, ankle, blood sugars, bone pain, buttocks, pain, radiates from her buttocks, leg pain/bone, leg, sugars, weight, |
1,358 | History of right leg pain. Leg pain is no longer present. | SOAP / Chart / Progress Notes | Leg Pain - Progress Note | HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. He still localizes it to a band between L4 and the sacrum. He initially had some right leg pain but states that this is minimal and intermittent at the present time. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1. There was no neural impingement. He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:, Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak. He denies any recent illness. He has no constitutional complaints such as fevers, chills or sweats. HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms. He has no dysphagia. Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope. Pulmonary: He denies any dyspnea or respiratory difficulties. GI: The patient has no abdominal pain, nausea or vomiting. GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria. Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities. Musculoskeletal: Denies any recent falls or near-falls. He denies any abnormalities of endocrine, immunologic, hematologic, organ systems. , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:, None., ,SOCIOECONOMIC STATUS:, Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs: Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2. He is sitting upright, alert and oriented and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. , ,On examination of the lumbar spine, he is minimally tender to palpation. There is no overt muscular spasm. His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension. Straight leg raises do not elicit any leg complaints on today's visit. Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain. The leg pain is no longer present. His pain level has improved., ,PLAN: ,1. The patient will take another Medrol Dosepak.,2. He can continue with physical therapy.,3. He also continues with the same lifting restrictions.,4. Follow up is within one week. | null |
1,359 | Patient status post lap band placement. | SOAP / Chart / Progress Notes | Lap Band Adjustment | REASON FOR VISIT:, Lap band adjustment.,HISTORY OF PRESENT ILLNESS:, Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. She was alert and oriented in no apparent distress. ,PROCEDURE: ,I was able to access her port. She does have an AP standard low profile. I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:, The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure. She will come back in two weeks for another adjustment as needed., | soap / chart / progress notes, lap band adjustment, lap band placement, lap band, |
1,360 | Patient with a history of ischemic cardiac disease and hypercholesterolemia. | SOAP / Chart / Progress Notes | Ischemic Cardiac Disease - Progress Note | HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old man who returns for recheck. He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test. He did walk for 8 minutes. The scan showed some mild inferior wall scar and ejection fraction was well preserved. He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:, Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY: ,Father died at the age of 84. He had a prior history of cancer of the lung and ischemic cardiac disease. Mother died in her 80s from congestive heart failure. He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY: ,Quit smoking in 1996. He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine: He has hypercholesterolemia treated with diet and medication. He reports that he did lose 10 pounds this year.,Neurologic: Denies any TIA symptoms.,Genitourinary: He has occasional nocturia. Denies any difficulty emptying his bladder.,Gastrointestinal: He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 225 pounds. Blood pressure: 130/82. Pulse: 83. Temperature: 96.4 degrees.,General Appearance: He is a middle-aged man who is not in any acute distress.,HEENT: Mouth: The posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1, S2, without gallops or rubs.,Abdomen: Without tenderness or masses.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Ischemic cardiac disease. This remains stable. He will continue on the same medication. He reports he has had some laboratory studies today.,2. Hypercholesterolemia. He will continue on the same medication.,3. Facial tic. We also discussed having difficulty with the facial tic at the left orbital region. This occurs mainly when he is under stress. He has apparently had numerous studies in the past and has seen several doctors in Wichita about this. At one time was being considered for some type of operation. His description, however, suggests that they were considering an operation for tic douloureux. He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close. Repeat neurology evaluation was advised. He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4. Immunization. Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment. We will have this discussed with him further when his laboratory results are back. | null |
1,361 | The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago. | SOAP / Chart / Progress Notes | Lobectomy - Followup | HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP: 117/78. RR: 18. P: 93.,WT: 186 lbs. RAS: 100%.,HEENT: Mucous membranes are moist. No cervical or supraclavicular lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIAC: Regular rate and rhythm without murmurs.,EXTREMITIES: No cyanosis, clubbing or edema.,NEURO: Alert and oriented x3. Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN: ,She is to return to clinic in six months with a chest CT. She was given a prescription for an ultrasound of the left lower extremity to rule out DVT. She will be called with the results. She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm. | soap / chart / progress notes, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer |
1,362 | Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation. | SOAP / Chart / Progress Notes | Laminectomy & Foraminotomy Followup | REASON FOR VISIT:, Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:, Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively. She had a medial breech of a right L4 pedicle screw. We took her back to the operating room same night and reinserted the screw. Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well. She had symptoms of what she thought was "restless leg syndrome" at that time. She has been put on ReQuip for this.,She returned. I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved. I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative. She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg. Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively. She is ambulating better than she was preoperatively. The pain is not as severe as it was preoperatively. The right leg pain is improved. The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain. No right lower extremity symptoms.,No infectious symptoms whatsoever. No fever, chills, chest pain, shortness of breath. No drainage from the wound. No difficulties with the incision.,FINDINGS: ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress. Alert and oriented x 3. Normocephalic, atraumatic. Respirations are normal and nonlabored. Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5. Gastroc-soleus strength is 3 to 4 out of 5. This has all been changed compared to preoperatively. Motor strength is otherwise 4 plus out of 5. Light touch sensation decreased along the medial aspect of the left foot. Straight leg raise test normal bilaterally.,The incision is well healed. There is no fluctuance or fullness with the incision whatsoever. No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5. There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN: ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07. The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms. However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection. I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization. I have reassured her that her spine appears stable at this time. She is happy with this.,I would like her to continue ambulating as much as possible. She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested. I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve. She knows that if she has any difficulties, she may follow up with me sooner. | soap / chart / progress notes, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine, |
1,363 | This patient has reoccurring ingrown infected toenails. | SOAP / Chart / Progress Notes | Infected Toenails | S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing on the borders of the toes. One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe. These lesions measure 0.5 cm in diameter each. I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1. Onychocryptosis., | soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected, |
1,364 | Patient with hypertension, syncope, and spinal stenosis - for recheck. | SOAP / Chart / Progress Notes | Hypertension - Progress Note | SUBJECTIVE:, The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:, Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS: ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily. She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES: ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed. Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She has one brother with asthma.,PERSONAL HISTORY:, Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints: She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg. She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac. She underwent several tests. She did have magnetic resonance angiography of the lower extremities and the aorta which were normal. She had nerve conduction study that showed several peripheral polyneuropathy. She reports that she has myelogram last week but has not got results of this. She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve. She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary: She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 227.2 pounds. Blood pressure: 144/72. Pulse: 80. Temperature: 97.5 degrees.,General Appearance: She is an elderly female patient who is not in acute distress.,Mouth: Posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1 and S2 without gallops or rubs.,Abdomen: Without masses or tenderness to palpation.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Hypertension. She is advised to continue with the same medication.,2. Syncope. She previously had an episode of syncope around Thanksgiving. She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3. Spinal stenosis. She still is being evaluated for this and possibly will have surgery in the near future. | soap / chart / progress notes, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea, |
1,365 | Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds. | SOAP / Chart / Progress Notes | HIV Followup - 1 | PROBLEM LIST:,1. HIV stable.,2. Hepatitis C chronic.,3. History of depression, stable off meds.,4. Hypertension, moderately controlled.,CHIEF COMPLAINT: , The patient comes for a routine followup appointment.,HISTORY OF PRESENTING ILLNESS: , This is a 34-year-old African American female who comes today for routine followup. She has no acute complaints. She reports that she has a muscle sprain on her upper back from lifting. The patient is a housekeeper by profession. It does not impede her work in anyway. She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication. No other associated complaints. No neurological deficits or other specific problems. The patient denies any symptoms associated with opportunistic infection.,PAST MEDICAL HISTORY:,1. Significant for HIV.,2. Hepatitis.,3. Depression.,4. Hypertension.,CURRENT MEDICATIONS:,1. She is on Trizivir 1 tablet p.o. b.i.d.,2. Ibuprofen over-the-counter p.r.n.,MEDICATION COMPLIANCE: , The patient is 100% compliant with her meds. She reports she does not miss any doses.,ALLERGIES: , She has no known drug allergies.,DRUG INTOLERANCE: ,There is no known drug intolerance in the past.,NUTRITIONAL STATUS: , The patient eats regular diet and eats 3 meals a day.,REVIEW OF SYSTEMS: , Noncontributory except as mentioned in the HPI.,LABORATORY DATA: , Most recent labs from 11/07.,RADIOLOGICAL DATA:, She has had no recent radiological procedures.,IMMUNIZATIONS: , Up-to-date.,SEXUAL HISTORY: , She has had no recent STDs and she is not currently sexually active. PPD status was negative in the past. PPD will be placed again today.,Treatment adherence counseling was performed by both nursing staff and myself. Again, the patient is a 100% compliant with her meds. Last dental exam was in 11/07, where she had 2 teeth extracted. Last Pap smear was 1 year ago was negative. The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram. She has no family history of breast cancer.,MENTAL HEALTH AND SUBSTANCE ABUSE: , The patient has a history of depression. No history of substance abuse.,ADVANCED DIRECTIVE: , Unknown.,PHYSICAL EXAMINATION:,GENERAL: This is a thinly built female, not in acute distress. VITAL SIGNS: Temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds. HEAD AND NECK: Reveals bilaterally reactive pupils. Supple neck. No thrush. No adenopathy. HEART: Heart sounds S1 and S2 regular. No murmur. LUNGS: Clear bilaterally to auscultation. ABDOMEN: Soft and nontender with good bowel sounds. NEUROLOGIC: She is alert and oriented x3 with no focal neurological deficit. EXTREMITIES: Peripheral pulses are felt bilaterally. She has no pitting pedal edema, clubbing or cyanosis. GU: Examination of external genitalia is unremarkable. There are no lesions.,LABORATORY DATA: , From 11/07 shows hemoglobin and hematocrit of 16 and 46. Creatinine of 0.6. LFTs within normal limits. Viral load of less than 48 and CD4 count of 918.,ASSESSMENT:,1. Human immunodeficiency virus, stable on Trizivir.,2. Hepatitis C with stable transaminases.,3. History of depression, stable off meds. | null |
1,366 | Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse. | SOAP / Chart / Progress Notes | Gen Med SOAP - 9 | SUBJECTIVE: ,This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently, but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs. It feels likes it is in his chest. He has been taking Allegra-D intermittently, but he is almost out and he needs a refill. The second problem, his foot continues to breakout. It seems like it was getting a lot better and now it is bad again. He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream. I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence. He works in the flint and it is really hot where he works and it has been quite humid lately. The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger. He is interested in getting that frozen today. Apparently, he tells me I froze a previous wart on him in the past and it went away. Next, he is interested in getting some blood test done. He specifically mentions the blood test for his prostate, which I informed him is called the PSA. He is 50 years old now. He will also be getting his cholesterol checked again because he has a history of high cholesterol. He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking. He says it is difficult to quit. He tells me he did quit chewing tobacco. I told him to keep trying to quit smoking. ,REVIEW OF SYSTEMS:, General: With this illness he has had no problems with fever. HEENT: Some runny nose, more runny nose than congestion. Respiratory: Denies shortness of breath. Skin: He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today. At times it is itchy.,OBJECTIVE: , His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16. General exam: The patient is nontoxic and in no acute distress. Ears: Tympanic membranes pearly gray bilaterally. Mouth: No erythema, ulcers, vesicles, or exudate noted. Neck is supple. No lymphadenopathy. Lungs: Clear to auscultation. No rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm without murmur. Extremities: No edema, cyanosis, or clubbing. Skin exam: I checked out the bottom of his right foot. He has peeling skin visible consistent with tinea pedis. On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart. The size of this wart is approximately 3 mm in diameter.,ASSESSMENT: ,1. Upper respiratory tract infection, persistent.,2. Tinea pedis.,3. Wart on the finger.,4. Hyperlipidemia.,5. Tobacco abuse.,PLAN: , The patient is getting a refill on Allegra-D. I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day. I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work. His wart has been present for some time now and he would like to get it frozen. I offered him the liquid nitrogen treatment and he did agree to it. I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart. He tolerated the procedure very well. I froze it once and I allowed for a 3 mm freeze zone. I gave him verbal wound care instructions after the procedure. Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test. Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days. | soap / chart / progress notes, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart, |
1,367 | One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well. | SOAP / Chart / Progress Notes | Gen Med SOAP - 7 | CHIEF COMPLAINT:, One-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I think the last steroid injection that she had with Dr. XYZ really did help. The patient denies any shortness of breath or cough. Has no nausea, vomiting, abdominal pain. No diarrhea or constipation. She states her appetite is good. She clears her plate at noon. She has had no fevers, chills, or sweats. The friend with her states she is doing very well. Seems to eat excellently at noontime, despite this, the patient continues to lose weight. When I asked her what she eats for breakfast and for supper, she states she really does not eat anything. Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time. She states she is really not hungry the rest of the time except at lunchtime. She denies any fevers, chills, or sweats. We did do some lab work at the last office visit and CBC was essentially normal. Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3. This is fairly stable for her. Liver enzymes were normal. TSH was normal. Free albumin was normal at 23. She is on different antidepressants and that may be causing some difficulties with unintentional weight loss.,MEDICATIONS: ,Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY:, Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.,SOCIAL HISTORY:, The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.,REVIEW OF SYSTEMS:, As above in HPI.,PHYSICAL EXAM:,General: This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face. States are clothes are fitting more loosely.,Vital Signs: Weight: 123, down 5 pounds from last month and down 11 pounds from May 2004. Blood pressure: 128/62. Pulse: 60. Respirations: 20. Temperature: 96.8.,Neck: Supple. Carotids are silent.,Chest: Clear to auscultation.,Cardiovascular: Regular rate and rhythm.,Abdomen: Soft and nontender, nondistended with positive bowel sounds. No organomegaly or masses are appreciated.,Extremities: Free of edema.,ASSESSMENT:,1. Unintentional weight loss. I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her.,2. Depression, doing well.,3. Paranoia, doing well.,4. Dementia, stable.,5. Osteoarthritis of the knees, pain is much improved.,PLAN:,1. Continue on current medications.,2. I did call and talk with doctor at hospital. We discussed different options. We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time. Connie will weigh the patient once a week and I will go ahead and see the patient in one month. We can see how she is doing at that time. If she continues to lose weight despite eating better, then I think we will need to do further evaluation. | null |
1,368 | Patient today with multiple issues. | SOAP / Chart / Progress Notes | Gen Med SOAP - 8 | SUBJECTIVE: , I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and stroke. This is the second time he has had significant gross hematuria this month. He also fell about a week ago and is complaining of buttock pain and leg pain. We did get x-rays of hips, knees, and ankles. Clearly, he has significant degenerative disease in all these areas. No fractures noted however. He felt that the pain is pretty severe and particularly worse in the morning. His sinuses are bothering him. He wonders about getting some nasal saline spray. We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.,PHYSICAL EXAMINATION: , Vitals: As in chart. The patient is alert, pleasant, and cooperative. He is not in any apparent distress. He is comfortable in a seated position. I did not examine him further today.,ASSESSMENT AND PLAN:,1. Hematuria. Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH. We will also obtain a repeat UA as he did describe to me some dysuria. However, I do not think this would account for the gross hematuria. He will be started on an aspirin 81 mg p.o. daily.,2. For the pain we will try him on Lortab. He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.,3. We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.,4. For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use. | soap / chart / progress notes, multiple issues, atrial fibrillation, gross hematuria, multiple, bph, fibrillation, hematuria, |
1,369 | Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology. | SOAP / Chart / Progress Notes | HIV Followup | HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease. His last CD4 count was 425, viral load was less than 50 in 08/07. He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus. He also has a history of hypertension and hypertriglyceridemia. He had been having increased urination and thirst. He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess. The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide. The patient reports that he has been taking the medication. He is in general feeling better. He says that his gluteal abscess is improving and he will be following up with Surgery today.,CURRENT MEDICATIONS:,1. Gabapentin 600 mg at night.,2. Metformin 1000 mg twice a day.,3. Glipizide 5 mg a day.,4. Flagyl 500 mg four times a day.,5. Flexeril 10 mg twice a day.,6. Paroxetine 20 mg a day.,7. Atripla one at night.,8. Clonazepam 1 mg twice a day.,9. Blood pressure medicine, name unknown.,REVIEW OF SYSTEMS:, He otherwise has a negative review of systems.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.) HEENT: Unremarkable except for some submandibular lymph nodes. His fundi are benign. NECK: Supple. LUNGS: Clear to auscultation and percussion. CARDIAC: Reveals regular rate and rhythm without murmur, rub or gallop. ABDOMEN: Soft and nontender without organomegaly or mass. EXTREMITIES: Show no cyanosis, clubbing or edema. GU: Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.,IMPRESSION:,1. Human immunodeficiency virus disease with stable control on Atripla.,2. Resolving left gluteal abscess, completing Flagyl.,3. Diabetes mellitus, currently on oral therapy.,4. Hypertension.,5. Depression.,6. Chronic musculoskeletal pain of unclear etiology.,PLAN: , The patient will continue his current medications. He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter. He has been encouraged to keep his appointment with his psychologist. | soap / chart / progress notes, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension, |
1,370 | Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain | SOAP / Chart / Progress Notes | Gen Med SOAP - 6 | SUBJECTIVE:, The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eating is okay. He is emptying his bladder okay. He denies dysuria. His back is hurting worse. He complains of right shoulder pain and neck pain over the last week but denies any injury. He reports that his cough is about the same.,CURRENT MEDICATIONS:, Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General: He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs: His age is 66. Temperature: 97.7. Blood pressure: 134/80. Pulse: 88. Weight: 201 pounds.,HEENT: Head was normocephalic. Examination of the throat reveals it to be clear. He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck: Supple without adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm.,Extremities: He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder. Back has limited range of motion. He is nontender to his back. Deep tendon reflexes are 2+ bilaterally in lower extremities. Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen: Soft, nontender without hepatosplenomegaly or mass. He has normal bowel sounds.,ASSESSMENT:,1. Clostridium difficile enteritis, improved.,2. Right shoulder pain.,3. Chronic low back pain.,4. Yeast thrush.,5. Coronary artery disease.,6. Urinary retention, which is doing better.,PLAN:, I put him on Diflucan 200 mg daily for seven days. We will have him stop his metronidazole little earlier at his request. He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course. I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.) Recheck with me in two to three weeks. | soap / chart / progress notes, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck, |
1,371 | Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change. | SOAP / Chart / Progress Notes | Hand Discomfort - Followup | REASON FOR RETURN VISIT: , Followup of left hand discomfort and systemic lupus erythematosus.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right. The patient was seen on 10/30/07. She had the same complaint. She was given a trial of Elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy. She was also given a prescription for Zostrix cream but was unable to get it filled because of insurance coverage. The patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits. The patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature. She has not had any night sweats or chills. She has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with GU or GI complaints. She is returning today for routine followup evaluation.,CURRENT MEDICATIONS:,1. Plaquenil 200 mg twice a day.,2. Fosamax 170 mg once a week.,3. Calcium and vitamin D complex twice daily.,4. Folic acid 1 mg per day.,5. Trilisate 1000 mg a day.,6. K-Dur 20 mEq twice a day.,7. Hydrochlorothiazide 15 mg once a day.,8. Lopressor 50 mg one-half tablet twice a day.,9. Trazodone 100 mg at bedtime.,10. Prempro 0.625 mg per day.,11. Aspirin 325 mg once a day.,12. Lipitor 10 mg per day.,13. Pepcid 20 mg twice a day.,14. Reglan 10 mg before meals and at bedtime.,15. Celexa 20 mg per day.,REVIEW OF SYSTEMS: , Noncontributory except for what was noted in the HPI and the remainder or complete review of systems is unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 155/84, pulse 87, weight 223 pounds, and temperature 99.2. GENERAL: She is a well-developed, well-nourished female appearing her staged age. She is alert, oriented, and cooperative. HEENT: Normocephalic and atraumatic. There is no facial rash. No oral lesions. LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs or gallops. EXTREMITIES: No cyanosis or clubbing. Sensory examination of the upper extremity decreased to light touch on the distal tips of the left second and third digits compared to the fifth digit. Positive Tinel sign. Full range of motion of the wrist with no evidence of motor atrophy or muscle loss.,LABORATORY DATA: ,WBC 5100, hemoglobin 11.1, hematocrit 32.8, and platelets 200,000. Westergren sedimentation rate of 47. Urinalysis is negative for protein and blood. Lupus serology is pending.,ASSESSMENT:,1. Systemic lupus erythematosus that is chronically stable at this point.,2. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.,3. Upper respiratory infection with cough, cold, and congestion.,RECOMMENDATIONS:,1. The patient will have a trial of a resting wrist splint at night for the next 4 to 6 weeks. If there is no improvement, the patient will return for corticosteroid injection of her carpal tunnel.,2. Azithromycin 5-day dose pack.,3. Robitussin Cough and Cold Flu to be taken twice a day.,4. Atarax 25 mg at bedtime for sleep.,5. The patient will return to the rheumatology clinic for a routine followup evaluation in 4 months. | null |
1,372 | The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure. | SOAP / Chart / Progress Notes | Gen Med SOAP - 11 | SUBJECTIVE:, The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to have strep. She was treated with penicillin and sent home. She returned about 8 o'clock after vomiting and a probable seizure. Temperature was 104.5; she was lethargic after that. She had an LP, which was unremarkable. She had blood cultures, which have not grown anything. The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:, She is alert, recovering from anesthesia. Head, eyes, ears, nose and throat are unremarkable. Chest is clear to auscultation and percussion. Abdomen is soft. Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift. CSF glucose was 68, protein was 16, and there were no cells. The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count. I am going to observe her overnight. | soap / chart / progress notes, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure, |
1,373 | The patient has NG tube in place for decompression. | SOAP / Chart / Progress Notes | Gen Med SOAP - 10 | SUBJECTIVE: , The patient has NG tube in place for decompression. She says she is feeling a bit better.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Pulse is 58 and blood pressure is 110/56.,SKIN: There is good skin turgor.,GENERAL: She is not in acute distress.,CHEST: Clear to auscultation. There is good air movement bilaterally.,CARDIOVASCULAR: First and second sounds are heard. No murmurs appreciated.,ABDOMEN: Less distended. Bowel sounds are absent.,EXTREMITIES: She has 3+ pedal swelling.,NEUROLOGICAL: The patient is alert and oriented x3. Examination is nonfocal.,LABORATORY DATA:, White count is down from 20,000 to 12.5, hemoglobin is 12, hematocrit 37, and platelets 199,000. Glucose is 157, BUN 14, creatinine 0.6, sodium is 131, potassium is 4.0, and CO2 is 31.,ASSESSMENT AND PLAN:,1. Small bowel obstruction/paralytic ileus, rule out obstipation. Continue with less aggressive decompression. Follow surgeon's recommendation.,2. Pulmonary fibrosis, status post biopsy. Manage as per pulmonologist.,3. Leukocytosis, improving. Continue current antibiotics.,4. Bilateral pedal swelling. Ultrasound of the lower extremity negative for DVT.,5. Hyponatremia, improving.,6. DVT prophylaxis.,7. GI prophylaxis. | soap / chart / progress notes, small bowel obstruction, paralytic ileus, decompression, ng tube, pedal swelling, prophylaxis |
1,374 | Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc. | SOAP / Chart / Progress Notes | Gen Med SOAP - 2 | SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged. ,ASSESSMENT:, ,1. NIDDM with improved control. ,2. Hypertension. ,3. Coronary artery disease status post coronary artery bypass graft. ,4. Degenerative arthritis. ,5. Hyperlipidemia. ,6. Hyperuricemia. ,7. Renal azotemia. ,8. Anemia. ,9. Fibroglandular breasts. ,PLAN:, We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed. | soap / chart / progress notes, general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery |
1,375 | Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 8 | SUBJECTIVE:, The patient is an 89-year-old lady. She actually turns 90 later this month, seen today for a short-term followup. Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended. She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily. She thinks, she also has an element of office hypertension. Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka. However, when we gave her samples of that she thought they were too big for her to swallow. Basically, she is just back on her previous blood pressure regimen. However, her blood pressure seems to be better today. Her daughter says that they do check it periodically and it is similar to today’s reading. Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade. We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems. She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve. She takes Tylenol p.r.n., which seems to be enough for her. She does not think she has any acid reflux symptoms or heartburn. She does take Tums t.i.d. and also Mylanta at night. She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth. They do heal up, but then she will get another one. She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor. They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:, Mostly otherwise as above.,OBJECTIVE:,General: She is a pleasant elderly lady. She is in no acute distress, accompanied by daughter.,Vital signs: Blood pressure: 128/82. Pulse: 68. Weight: 143 pounds.,HEENT: No acute changes. Atraumatic, normocephalic. On mouth exam, she does have dentures. She removed her upper denture. I really do not see any sores at all. Her mouth exam was unremarkable.,Neck: No adenopathy, tenderness, JVD, bruits, or mass.,Lungs: Clear.,Heart: Regular rate and rhythm.,Extremities: No significant edema. Reasonable pulses. No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable. No other focal or neurological deficits grossly.,IMPRESSION:,1. Hypertension, better reading today.,2. Right arm symptoms, resolved.,3. Depression probably somewhat improved with Lexapro and she will just continue that. She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4. Perhaps a very subtle tremor. I will just watch that.,5. Osteoporosis.,6. Osteoarthritis.,PLAN:, I think I will just watch everything for now. I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half. I offered to see her for again short-term followup. However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner. She might get a flu shot here in the next few weeks. Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that. | soap / chart / progress notes, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose, |
1,376 | General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, | SOAP / Chart / Progress Notes | Gen Med SOAP - 5 | S:, The patient is here today with his mom for several complaints. Number one, he has been having issues with his right shoulder. Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. He has been having issues ever since. He is having difficulties raising his arm over his head. He does have some intermittent numbness in his fingers at night. He is not taking any anti-inflammatories or pain relievers. He is also complaining of a sore throat. He did have some exposure to Strep and he has a long history of strep throat. Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation. He is also being seen for ADHD by Dr. B. Adderall and Zoloft. He takes these once a day. He does notice when he does not take his medication. He is doing well in school. He is socializing well. He is maintaining his weight and tolerating the medications. However, he is having issues with anger control. He realizes when he has anger outbursts that it is a problem. His mom is concerned. He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:, Reviewed and unchanged.,O:, VSS. In general, patient is A&Ox3. NAD. Heart: RRR. Lungs: CTA. HEENT: Unremarkable. He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip. Musculoskeletal: Limited in range of motion, active on the right. He stops at about 95 degrees. No muscle weakness. Neurovascularly intact. Negative biceps tenderness. Psych: No suicidal, homicidal ideations. Answering questions appropriately. No hallucinations. | soap / chart / progress notes, general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent |
1,377 | General Medicine SOAP note. | SOAP / Chart / Progress Notes | Gen Med SOAP - 3 | S:, XYZ is in today not feeling well for the last three days. She is a bit sick with bodyaches. She is coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. She is sleeping okay. She does not feel like she needs anything for the cough. She did call in yesterday, and got a refill of her Keflex. She took two Keflex this morning and she is feeling a little bit better now. She is tearful, just tired of feeling ran down.,O:, Vital signs as per chart. Respirations 15. Exam: Nontoxic. No acute distress. Alert and oriented. HEENT: TMs are clear bilaterally without erythema or bulging. Clear external canals. Clear tympanic. Conjunctivae are clear. Clear nasal mucosa. Clear oropharynx with moist mucous membranes. NECK is soft and supple without lymphadenopathy. LUNGS are coarse with no severe rhonchi or wheezes. HEART is regular rate and rhythm without murmur. ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates. We will send the x-ray for over-read.,Influenza test is negative. Rapid strep screen is negative.,A:, Bronchitis/URI.,P: , ,1. Motrin as needed for fever and discomfort.,2. Push fluids.,3. Continue on the Keflex.,4. Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed. | soap / chart / progress notes, bodyaches, alert and oriented, no acute distress, soap, diarrhea, general medicine, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented, |
1,378 | Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea. | SOAP / Chart / Progress Notes | Gen Med SOAP | SUBJECTIVE: , This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was something else. He says he is having a lot of palpitations. He gets a fluttering feeling in his chest. He has been very tired over two weeks as well. His job has been really getting to him. He has been feeling nervous and anxious. It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. These symptoms are not triggered by exertion. He had similar symptoms about 9 or 10 years ago. At that time he went through a full workup. Everything ended up being negative and they gave him something that he took for his nerves and he says that helped. Unfortunately, he does not remember what it was. Also over the last three days he has had some intestinal problems. He has had some intermittent nausea and his stools have been loose. He has been having some really funny green color to his bowel movements. There has been no blood in the stool. He is not having any abdominal pain, just some nausea. He does not have much of an appetite. He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16. General exam: The patient is nontoxic and in no acute distress. There is no labored breathing. Psychiatric: He is alert and oriented times 3. Ears: Tympanic membranes pearly gray bilaterally. Mouth: No erythema, ulcers, vesicles, or exudate noted. Eyes: Pupils equal, round, and reactive to light bilaterally. Neck is supple. No lymphadenopathy. Lungs: Clear to auscultation. No rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm without murmur. Extremities: No edema, cyanosis, or clubbing.,ASSESSMENT: ,1. Palpitations, possibly related to anxiety.,2. Fatigue.,3. Loose stools with some green color and also some nausea. There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks. He says his work is definitely contributing to some of his symptoms and he feels stressed. He is leaving for a vacation very soon. Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him. My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis. A 12-lead EKG was performed on him in the office today. This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news. I am going to send him to the lab from our office to get the following tests done: Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray. Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital. We were able to squeeze him in. His appointment is at 8:15 in the morning. He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck. I am not going to be here so he is going to see Dr. X. Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ. Certainly, if something comes up we may need to postpone his trip. We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago. In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety. I talked about Ativan, how it works. I talked about the side effects. I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck. I took him off of work today and tomorrow so he could rest. | soap / chart / progress notes, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety, |
1,379 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | Gen Med SOAP - 1 | SUBJECTIVE:, | soap / chart / progress notes, progress note, clear to auscultation, s1, s2, s3, s4, blood pressure, clubbing, cyanosis, general medicine, peripheral edema, rubs, tenderness, abdomen, pressure, soap, blood |
1,380 | General Medicine SOAP note. | SOAP / Chart / Progress Notes | Gen Med SOAP - 4 | S:, ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that she wants to stop the Coumadin. She is tired of blood draws. We have had a difficult time getting her regulated. No chest pains. No shortness of breath. She is moving around a little bit better. Her arm does not hurt her. Her back pain is improving as well.,O:, Vital signs as per chart. Respirations 15. Exam: Nontoxic. No acute distress. Alert and oriented. HEENT: TMs are clear bilaterally without erythema or bulging. Clear external canals. Clear tympanic. Conjunctivae are clear. Clear nasal mucosa. Clear oropharynx with moist mucous membranes. NECK is soft and supple. LUNGS are clear to auscultation. HEART is irregularly irregular, mildly tachycardic. ABDOMEN is soft and nontender. EXTREMITIES: No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1. | soap / chart / progress notes, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, general medicine, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial, |
1,381 | Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 9 | SUBJECTIVE:, The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in the morning when she is up, but then through the day it begins to swell again. Lately it is staying bigger and she somewhat uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. The other problem she had was she has had pain in her shoulder and back. These occurred about a year ago, but the pain in her left shoulder is of most concern to her. She feels like the low back pain is just a result of a poor mattress. She does not remember hurting her shoulder, but she said gradually she has lost some mobility. It is hard time to get her hands behind her back or behind her head. She has lost strength in the left shoulder. As far as the blood count goes, she had an elevated white count. In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up. She also complains of a lot of frequency with urination and nocturia times two to three. She has gained weight; she thinks about 12 pounds since March. She now weighs 284. Fortunately, her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much. She denies chest pain, but she does feel like she is becoming gradually more short of breath. She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much. Towards the end of the day her leg was really swollen. I reviewed her lab work. Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,OBJECTIVE:,General: The patient is a very pleasant 44-year-old white female quite obese.,Vital Signs: Blood pressure: 122/70. Temperature: 98.6.,HEENT: Head: Normocephalic. Ears: TMs intact. Eyes: Pupils round, and equal. Nose: Mucosa normal. Throat: Mucosa normal.,Lungs: Clear.,Heart: Regular rate and rhythm.,Abdomen: Soft and obese.,Extremities: A lot of fluid in both legs, but especially the left leg is really swollen. At least 2+ pedal edema. The right leg just has a trace of edema. She has pain in her low back with range of motion. She has a lot of pain in her left shoulder with range of motion. It is hard for her to get her hand behind her back. She cannot get it up behind her head. She has pain in the anterior left shoulder in that area.,ASSESSMENT:,1. Multiple problems including left leg swelling.,2. History of leukocytosis.,3. Joint pain involving the left shoulder, probably impingement syndrome.,4. Low back pain, chronic with obesity.,5. Obesity.,6. Frequency with urination.,7. Tobacco abuse.,PLAN:,1. I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel. We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.,2. Elevate her leg as much as possible and wear support hose if possible. Keep her foot up during the day. We will see her back in two weeks. We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain. If her shoulder pain is not any better, we probably should refer her on over to orthopedist. We did do x-rays of her shoulder today that did not show anything remarkable. See her in two weeks or p.r.n. | soap / chart / progress notes, leg swelling, leukocytosis, joint pain, left shoulder, low back pain, obesity, frequency with urination, tobacco abuse, multiple problems, blood count, blood pressure, leg, shoulder, tobacco, swelling, weight |
1,382 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 2 | 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. | soap / chart / progress notes, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, general medicine, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress, |
1,383 | A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 6 | SUBJECTIVE:, This 3-year-old male is brought by his mother with concerns about his eating. He has become a very particular eater, and not eating very much in general. However, her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit. After this occurred several times, they stopped giving him carrots. Last week, he ate some celery and the same thing happened. They had not given him any of that since. He eats other foods without any apparent pain or vomiting. Bowel movements are normal. He does have a history of reactive airway disease, intermittently. He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:, He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs: Weight: 31.5 pounds, which is an increase of 2.5 pounds since May. Temperature is 97.1. He certainly appears in no distress. He is quite interested in looking at his books.,Neck: Supple without adenopathy.,Lungs: Clear.,Cardiac: Regular rate and rhythm without murmurs.,Abdomen: Soft without organomegaly, masses, or tenderness.,ASSESSMENT:, Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown.,PLAN:, I talked with mother about this. Certainly, it does not suggest any kind of an allergic reaction, nor obstruction. At this time, they will simply avoid those foods. In the future, they may certainly try those again and see how he tolerates those. I did encourage a wide variety of fruits and vegetables in his diet as a general principle. If worsening symptoms, she is welcome to contact me again for reevaluation. | soap / chart / progress notes, eating, foods, vomiting, reactive airway disease, raw carrots, carrots, |
1,384 | Patient with a three-day history of emesis and a four-day history of diarrhea | SOAP / Chart / Progress Notes | Gen Med Progress Note - 7 | SUBJECTIVE:, The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened. But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad. The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days. He has not had any emesis today. He has urinated this morning. His parents are both concerned because he had a fever of 103 last night. Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis. He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.,MEDICATIONS: ,None.,ALLERGIES: ,He has no known drug allergies.,REVIEW OF SYSTEMS:, Negative as far as sore throat, earache, or cough.,PHYSICAL EXAMINATION:,General: He is awake and alert, no acute distress.,Vital Signs: Blood pressure: 106/75. Temperature: 99. Pulse: 112. Weight is 54 pounds.,HEENT: His TMs are normal bilaterally. Posterior pharynx is unremarkable.,Neck: Without adenopathy or thyromegaly.,Lungs: Clear to auscultation.,Heart: Regular rate and rhythm without murmur.,Abdomen: Benign.,Skin: Turgor is intact. His capillary refill is less than 3 seconds.,LABORATORY: , White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos. His platelet count on his CBC is 215.,ASSESSMENT:, Viral gastroenteritis.,PLAN:, The parents did point out to me a rash that he had on his buttock. There were some small almost pinpoint erythematous patches of papules that have a scab on them. I did not see any evidence of petechiae. Therefore, I just reassured them that this is a viral gastroenteritis. I recommended that they stop giving him juice and just go with the Gatorade and water. He is to stay away from milk products until his diarrhea and stomach upset have calmed down. We talked about BRAT diet and slowly advancing his diet as he tolerates. They have used some Kaopectate, which did not really help with the diarrhea. Otherwise follow up as needed. | soap / chart / progress notes, diarrhea, emesis, history of, gastroenteritis, viral, brat diet, progress note, |
1,385 | A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 5 | SUBJECTIVE:, The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. She follows with Dr. XYZ on her hypertension, as well as myself. She continues to gain weight. Diabetes is therefore a major concern. In fact, her dad had diabetes and she has a brother who has diabetes. The patient also has several additional concerns she brings up today. One is that her left knee continues to bother her and it hurts. She cannot really isolate where the pain is, it just seems to hurt through her knee. She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999. There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially. She would like to have this x-rayed again today. She is certainly not interested in any surgery. She has noted that it particularly hurts to kneel. In addition, she complains of her stools being a baby-yellow. She has rectal bleeding off and on. It is bright red. She had a colonoscopy done in 1999. She does have a family history of colon cancer questionable in her mother, who is deceased. She complains of some diffuse abdominal pain off and on. She has given up fast foods and her pop and this has not seemed to help. She does admit however, that she is not eating right. Sometimes her stools are hard. Sometimes they are runny. The blood does not really seem to be related to necessarily a hard stool. It is always bright red and will sometimes drip into the toilet. Over the last couple of days, she had also been sneezing and has had an itchy throat. She tried some Claritin and this did not help. She has had some body aches. She is finally feeling better today with this. She also is questioning whether she has some sleep apnea. She will awaken suddenly in the middle of the night. She was told that she does snore. She does not smoke. As stated, she has gained significant weight.,GYNECOLOGICAL HISTORY: , She does not bleed. She has both ovaries, as well as her uterus and cervix. She is on no hormonal therapy.,PREVENTATIVE HISTORY:, She is not exercising. She does not do self breast examinations. She has recently had her mammogram and it was unremarkable. She does take her low-dose aspirin daily as well as her multivitamin. She does wear her seatbelt. As previously noted, she does not smoke or drink alcohol.,PAST MEDICAL, FAMILY AND SOCIAL HISTORY:, Per health summary sheet, unchanged.,REVIEW OF SYSTEMS:, Unremarkable with the exception of that above. ,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:, Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.,OBJECTIVE:,General: Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,Vitals: Her weight today is 246 pounds. In March of 2002 she weighed 231 pounds. In March 2001 she weighed 203 pounds. Her blood pressure is 160/78. Pulse is 84. Respiratory rate of 20. She is afebrile.,HEENT: Head is of normocephalic, atraumatic. PERLA. Conjunctivae clear. TMs are unremarkable and canals are patent. Nasal mucosa is slightly reddened. Nares are patent. Throat shows some clear posterior pharyngeal drainage. Throat is slightly reddened. Non-exudative. No oral lesions or dental caries noted.,Neck: Supple, No adenopathy. Thyroid without any nodules or enlargements, no JVD or carotid bruits.,Heart: Regular rate and rhythm without murmurs, clicks or rubs. PMI is nondisplaced.,Lungs: Clear to A&P. No CVA tenderness.,Breast exam: Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge. Breasts were examined both lying and sitting.,Abdomen: Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses. Non tender.,Pelvic exam: BUS unremarkable. Speculum exam shows normal physiologic discharge. There are some atrophic vaginal changes. Cervix visualized, no gross abnormalities. Pap smear obtained. Bimanual is negative for any adnexal masses or tenderness. Rectal exam is negative for any adnexal masses or tenderness. No rectal masses. She does have some external hemorrhoids, none of which are inflamed at this time. No palpable rectal masses.,Neuromusculoskeletal exam: Cranial nerves II-XII are grossly intact. No cerebellar signs are noted. No evidence of a gait disturbance. DTRs are 1+/4+ and equal throughout. Good uptoeing. Skin: Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,ASSESSMENT:,1. Weight-gain.,2. Hypertension.,3. Lipometabolism disorder.,4. Rectal bleeding.,5. Left knee pain.,6. Question of sleep apnea.,7. Upper respiratory infection, improving.,8. Gynecological examination is unremarkable for her age.,PLAN:, We discussed at length, the issue of sleep apnea and its negative sequela. I have recommended that she be referred for a sleep study. She is certainly at risk for sleep apnea. She refuses this. I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better. I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable. I reviewed this with her. I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them. I will dictate Dr. XYZ a note. I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort. She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her. This however, has been some time ago. I suspect she has an element of irritable bowel syndrome. I have strongly encouraged weight reduction, both through diet and exercise. I would like to see her back in the office in six months. I did retake her blood pressure today and it was 130/70. She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK. I will her mail the results. I have strongly encouraged medication management if her lipids are elevated. I think she is amenable to this. Her DEXA scan is up to date having been done on 04/09/03. I do not recommend one this year. | null |
1,386 | The patient is in complaining of headaches and dizzy spells. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 4 | SUBJECTIVE:, The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias. She has noticed a few more bruises on her legs. No fever or chills with slight cough. She has had more chest pains but not at present. She does have a little bit of nausea but no vomiting or diarrhea. She complains of some left shoulder tenderness and discomfort. She reports her blood sugar today after lunch was 155.,CURRENT MEDICATIONS:, She is currently on her nystatin ointment to her lips q.i.d. p.r.n. She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,ALLERGIES: , Sulfa, erythromycin, Macrodantin, and tramadol.,OBJECTIVE:,General: She is a well-developed, well-nourished, obese female in no acute distress.,Vital Signs: Her age is 55. Temperature: 98.2. Blood pressure: 110/70. Pulse: 72. Weight: 174 pounds.,HEENT: Head was normocephalic. Throat: Clear. TMs clear.,Neck: Supple without adenopathy.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur.,Abdomen: Soft, nontender without hepatosplenomegaly or mass.,Extremities: Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted. Her shoulders have full range of motion. She has minimal tenderness to the left shoulder anteriorly.,Skin: There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,ASSESSMENT:,1. Headaches.,2. Dizziness.,3. Atypical chest pains.,4. Chronic renal failure.,5. Type II diabetes.,6. Myalgias.,7. Severe anxiety (affect is still quite anxious.),PLAN:, I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m. I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin. Recheck in one week. I think her dizziness is multifactorial and due to enlarged part of her anxiety. I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin. | soap / chart / progress notes, headaches and dizzy spells, chest pains, shoulder, progress, headaches, |
1,387 | Sepsis due to urinary tract infection. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 13 | SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS: Temperature is 95.4. Highest temperature recorded over the past 24 hours is 102.1.,CHEST: Examination of the chest is clear to auscultation.,CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.,ABDOMEN: Benign. Right renal angle is tender. Bowel sounds are positive.,EXTREMITIES: There is no swelling.,NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5. Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000. BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1. Sepsis due to urinary tract infection. Urine culture shows Escherichia coli, resistant to Levaquin. We changed to doripenem.,2. Urinary tract infection, we will treat with doripenem, change Foley catheter,3. Hypotension. Resolved, continue intravenous fluids.,4. Ischemic cardiomyopathy. No evidence of decompensation, we with monitor.,5. Diabetes type 2. Uncontrolled. Continue insulin sliding scale.,6. Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7. History of coronary artery disease. Troponin indeterminate. Cardiologist intends no further workup. Continue medical treatment. Most likely troponin is secondary to impaired clearance. | soap / chart / progress notes, sepsis, escherichia coli, urinary tract infection, doripenem, troponin, urinary, infection |
1,388 | Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 12 | SUBJECTIVE: , The patient was seen and examined. He feels much better today, improved weakness and decreased muscular pain. No other complaints.,PHYSICAL EXAMINATION:,GENERAL: Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS: Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, O2 saturation 99% on 3 L.,HEENT: NC/T, PERRLA, EOMI.,NECK: Supple.,HEART: Regular rate and rhythm.,RESPIRATORY: Clear bilateral.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses present bilateral.,LABORATORY DATA: , Total CK coming down 70,142 from 25,573, total CK is 200, troponin is 2.3 from 1.9 yesterday.,BNP, blood sugar 93, BUN of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and CO2 of 22.,Liver function test, AST 704, ALT 298, alkaline phosphatase 67, total bilirubin 0.3. CBC, WBC count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204. Blood cultures are still pending.,Ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease. Doppler of lower extremities negative for DVT., ,ASSESSMENT AND PLAN:,1. Rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission. Continue IV fluids. We will monitor.,2. Acute on chronic renal failure. We will follow up with Nephrology recommendation.,3. Anemia, drop in hemoglobin most likely hemodilutional. Repeat CBC in a.m.,4. Leukocytosis, improving.,5. Elevated liver enzyme, most likely secondary to rhabdomyolysis. The patient denies any abdominal pain and ultrasound is unremarkable.,6. Hypertension. Blood pressure controlled.,7. Elevated cardiac enzyme, follow up with Cardiology recommendation.,8. Obesity.,9. Deep venous thrombosis prophylaxis. Continue Lovenox 40 mg subcu daily. | soap / chart / progress notes, rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity, cardiac enzyme, blood pressure, |
1,389 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 3 | CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:, A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly., ,PAST MEDICAL HISTORY:, Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.,General: A 70-year-old female who does not appear to be in acute distress. ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull. | null |
1,390 | Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 10 | CHIEF COMPLAINT:, The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if she bends over then stands up quickly. She has had no nausea, vomiting, or diarrhea. She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year. The patient is wanting to lose weight before her surgery. She is concerned about possible coronary disease or stroke risk. She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable. She has had fairly normal lipid panel, last being checked on 11/26/2003. Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129. The patient is a nonsmoker. Her fasting glucose in November 2003 was within normal limits at 94. Her fasting insulin level was normal. Repeat nonfasting glucose was 109 on 06/22/2004. She does not have history of diabetes. She does not exercise regularly and is not able to because of knee pain. She also has had difficulties with low back pain. X-ray of the low back did show a mild compression fracture of L1. She has had no falls that would contribute to a compression fracture. She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan. She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,CURRENT MEDICATIONS:, Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.,ALLERGIES: ,Bactrim, which causes nausea and vomiting, and adhesive tape.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Depression.,3. Myofascitis of the feet.,4. Severe osteoarthritis of the knee.,5. Removal of the melanoma from the right thigh in 1984.,6. Breast biopsy in January of 1997, which was benign.,7. History of Holter monitor showing ectopic beat. Echocardiogram was normal. These were in 1998.,8. Compression fracture of L1, unknown cause. She had had no injury. Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.,SOCIAL HISTORY:, The patient is married. She is a nonsmoker and nondrinker.,REVIEW OF SYSTEMS:, As per the HPI.,PHYSICAL EXAMINATION:,General: This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.,Vital signs: Weight: Refused. Blood pressure: 148/82, on recheck by myself with a large cuff, it was 125/60. Pulse: 64. Respirations: 20. Temperature: 96.3.,Neck: Supple. Carotids are silent.,Chest: Clear to auscultation.,Cardiovascular: Revealed a regular rate and rhythm without murmur, S3, or S4.,Extremities: Revealed no edema.,Neurologic: Grossly intact.,RADIOLOGY: EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.,ASSESSMENT:,1. Hypertension, well controlled.,2. Family history of cerebrovascular accident.,3. Compression fracture of L1, mild.,4. Osteoarthritis of the knee.,5. Mildly abnormal chest x-ray.,PLAN:,1. We will get a C-reactive protein cardiac.,2. We discussed weight loss options. I would recommend Weight Watchers or possibly having her see a dietician. She will think about these options. She is not able to exercise regularly right now because of knee pain.,3. We would recommend a screening colonoscopy. She states that we discussed this in the past and she canceled her appointment to have that done. She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.,4. We will start Fosamax 70 mg once weekly. She is to take this in the morning on an empty stomach with full glass of water. She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.,5. I would like to see her back in one to two months. At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing. One would also consider preoperative beta-blocker for cardiac protection. | null |
1,391 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 1 | 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. | soap / chart / progress notes, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin, |
1,392 | Patient having foot pain. | SOAP / Chart / Progress Notes | Foot Pain - SOAP | 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 05/14/2004. 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 June 15, 2004, 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. | soap / chart / progress notes, soap, foot pain, primary care physician, project access, insurance, foot, project, access, care, appointment |
1,393 | The patient states that he feels sick and weak. | SOAP / Chart / Progress Notes | Gen Med Progress Note | SUBJECTIVE:, The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS: Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL: The patient looks tired.,HEENT: Oral mucosa is dry.,CHEST: Clear to auscultation. He states that he has a mild cough, not productive.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Soft and nontender. Bowel sounds are positive. Murphy's sign is negative.,EXTREMITIES: There is no swelling.,NEURO: The patient is alert and oriented x 3. Examination is nonfocal.,LABORATORY DATA: , White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000. Glucose is in the low 100s. Comprehensive metabolic panel is unremarkable. UA is negative for infection.,ASSESSMENT AND PLAN:,1. Fever of undetermined origin, probably viral since white count is normal. Would continue current antibiotics empirically.,2. Dehydration. Hydrate the patient.,3. Prostatic hypertrophy. Urologist, Dr. X.,4. DVT prophylaxis with subcutaneous heparin. | soap / chart / progress notes, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature, |
1,394 | Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access. | SOAP / Chart / Progress Notes | Fundoplication & Gastrostomy Followup | REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN: ,The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future. | soap / chart / progress notes, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication, |
1,395 | Follow up consultation, second opinion, foreskin. | SOAP / Chart / Progress Notes | Foreskin - Followup | REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well. He has a relatively unremarkable foreskin. At this point in time, he otherwise seems to be doing reasonably well. The question is about the foreskin. He otherwise has no other significant issues. Severity low, ongoing since birth two weeks. Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:, Male exam. Normal and under the penis, report normal uncircumcised 2-week-old. He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe. I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision. This kid should otherwise do reasonably well.,PLAN: ,Follow up as needed. But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision. | soap / chart / progress notes, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin, |
1,396 | 5-month recheck on type II diabetes mellitus, as well as hypertension. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 11 | 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. | |
1,397 | Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma. | SOAP / Chart / Progress Notes | Evaluation of Allergies | HISTORY:, A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION: ,1. Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2. History of fibromyalgia.,3. History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4. History of chronic fatigue.,5. History of hypothyroidism.,6. History of depression.,7. History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation. The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested. The patient will follow up after RAST allergy testing for further treatment recommendations. At this point, no changes in her medication were prescribed until her followup visit. | soap / chart / progress notes, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy |
1,398 | Fifth disease with sinusitis | SOAP / Chart / Progress Notes | Fifth Disease - SOAP | 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. | soap / chart / progress notes, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx, |
1,399 | Preop evaluation regarding gastric bypass surgery. | SOAP / Chart / Progress Notes | Gastric Bypass - Preop Eval | REASON FOR VISIT:, Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3. Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds. Abdomen: Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:, The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks. Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection. Questions regarding hospital course and recovery were addressed. We will continue on the Medifast diet until the time of surgery and cleared for surgery. | soap / chart / progress notes, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass, |
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