SOAP / Chart / Progress Notes
Sample Name: Lobectomy - Followup
Description: The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.
She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.
MEDICATIONS: Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.
PHYSICAL EXAMINATION: BP: 117/78. RR: 18. P: 93.
WT: 186 lbs. RAS: 100%.
HEENT: Mucous membranes are moist. No cervical or supraclavicular lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: No cyanosis, clubbing or edema.
NEURO: Alert and oriented x3. Cranial nerves II through XII intact.
ASSESSMENT: The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.
PLAN: She is to return to clinic in six months with a chest CT. She was given a prescription for an ultrasound of the left lower extremity to rule out DVT. She will be called with the results. She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.
Keywords: soap / chart / progress notes, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer,