SOAP / Chart / Progress Notes
Sample Name: CyberKnife Treatment - Followup
Description: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.
Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.
MEDICATIONS: Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.
PHYSICAL EXAMINATION: BP: 122/86. Temp: 96.8. HR: 79. RR: 26. RAS: 100%.
HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.
NECK: Supple without masses or lymphadenopathy.
LUNGS: Clear to auscultation bilaterally
EXTREMITIES: No cyanosis, clubbing or edema.
ASSESSMENT: The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.
PLAN: She is to return to clinic in three months with a PET CT.
Keywords: soap / chart / progress notes, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,