Medical Specialty:
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.

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.

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.

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