Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: 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.
(Medical Transcription Sample Report)
REASON FOR VISIT:
Six-month follow-up visit for CAD.
He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.
He has been having a lot of pain in his back and pain in his left knee. He is also having trouble getting his nerves under control. He is having stomach pains and occasional nausea. His teeth are bad and need to be pulled.
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.MEDICATIONS:
Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.REVIEW OF SYSTEMS:
BP: 140/78. HR: 65. WT: 260 pounds (which is up one pound). There is no JVD. No carotid bruit. Cardiac: Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border. Lungs: Clear. Abdomen: Mildly tender throughout the epigastrium.
Extremities: No edema.EKG:
Sinus rhythm, left axis deviation, otherwise unremarkable.
Echocardiogram (for dyspnea and CAD): Normal systolic and diastolic function. Moderate LVH. Possible gallstones seen.IMPRESSION:
1. CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD. He has a stent in his LAD and his obtuse marginal. Fairly stable.
2. Dyspnea-Seems to be due to his weight and the disability from his knee. His echocardiogram shows no systolic or diastolic function.
3. Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.
4. Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.
5. Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.
6. Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.
7. Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.PLAN:
1. Discontinue Plavix.
2. Aspirin reduced to 81 mg a day.
3. Lorcet and Xanax prescriptions given.
4. Refer over to Scotland Orthopedics.
5. Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.
soap / chart / progress notes, anxiety, cad, palpitations, lightheadedness, shortness of breath, coronary artery disease,
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