SOAP / Chart / Progress Notes
Sample Name: Progress Note - Iron Deficiency Anemia
Description: Patient developed iron deficiency anemia and had blood in his stool.
(Medical Transcription Sample Report)
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.
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.
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.
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.
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