SOAP / Chart / Progress Notes
Sample Name: Anemia & Leukemia Followup
Description: Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.
(Medical Transcription Sample Report)
1. Chronic lymphocytic leukemia (CLL).
2. Autoimmune hemolytic anemia.
3. Oral ulcer.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. He comes in to clinic today for follow-up and complete blood count. At his last office visit we discontinued this prophylactic antivirals and antibacterial.
CURRENT MEDICATIONS: Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.
REVIEW OF SYSTEMS: The patient reports ulcer on his tongue and his lip. He has been off of Valtrex for five days. He is having some difficulty with his night vision with his left eye. He has a known cataract. He denies any fevers, chills, or night sweats. He continues to have headaches. The rest of his review of systems is negative.
VITALS: BP: 120/74. HEART RATE: 72. TEMP: 97.8. Weight: 112.7 kg.
GEN: He has a obvious cold sore on his bottom lip on the left.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. His oropharynx is notable for ulcer on his tongue. No ulcers on his buccal mucosa.
NECK: Supple. He has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
EXT: No lower extremity edema.
LABORATORY DATA: His white blood cell count is 4.6, hemoglobin 14.2, hematocrit 42, and platelets 207,000.
ASSESSMENT/PLAN: This is a 72-year-old gentleman with chronic lymphocytic leukemia on chronic steroids for autoimmune hemolytic anemia. His blood counts are relatively stable at 5 mg of prednisone every other day. We will plan on putting him back on the Valtrex and decreasing his steroids to 1 mg daily. I will see him back in clinic in a week.
Keywords: soap / chart / progress notes, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune,