SOAP / Chart / Progress Notes
Sample Name: Polycythemia Rubra Vera
Description: Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Polycythemia rubra vera.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.
CURRENT MEDICATIONS: Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.
REVIEW OF SYSTEMS: The patient's chief complaint is her weight. She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key. She has questions as to whether or not there would be any contra indications to her going on the diet. Otherwise, she feels great. She had family reunion in Iowa once in four days out there. She continues to volunteer Hospital and is walking and enjoying her summer. She denies any fevers, chills, or night sweats. She has some mild constipation problem but has had under control. The rest of her review of systems is negative.
VITALS: BP: 120/56. HEART RATE: 80. TEMP: 97.3. Weight: 81.8 kg.
GEN: She looks great, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Her oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Distended. She has positive bowel sounds. No hepatosplenomegaly.
EXT: No lower extremity edema.
SKIN: No skin rash.
LABORATORY DATA: Hematocrit in July was 40.5. Her most recent hematocrit was 42. She again did not require phlebotomy.
ASSESSMENT/PLAN: This is an 83-year-old gentleman with polycythemia. She has not required phlebotomy for quite some time. My plan is to change her standing order for hematocrit check every two months as oppose to monthly. I will see her back in clinic in three months.
Keywords: soap / chart / progress notes, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia,