Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Subjective, Objective, Assessment, Plan. Progress notes, followup notes, etc.
Breast Cancer Followup - 1
Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.
Breast Radiation Therapy Followup
Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.
Bunions and Calluses
A 60-year-old female presents today for care of painful calluses and benign lesions.
CAD - 6-Month Followup
He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.
Dietary consultation for carbohydrate counting for type I diabetes.
Cardiology Progress Note
Problem of essential hypertension. Symptoms that suggested intracranial pathology.
Cardiology Progress Note - 1
Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.
Care Conference With Family
Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.
Cataract - Second Opinion
The patient seeks evaluation for a second opinion concerning cataract extraction.
Cataract Extraction Followup
Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.