SOAP / Chart / Progress Notes
Sample Name: HIV Followup
Description: Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old white male with a history of HIV disease. His last CD4 count was 425, viral load was less than 50 in 08/07. He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus. He also has a history of hypertension and hypertriglyceridemia. He had been having increased urination and thirst. He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess. The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide. The patient reports that he has been taking the medication. He is in general feeling better. He says that his gluteal abscess is improving and he will be following up with Surgery today.
1. Gabapentin 600 mg at night.
2. Metformin 1000 mg twice a day.
3. Glipizide 5 mg a day.
4. Flagyl 500 mg four times a day.
5. Flexeril 10 mg twice a day.
6. Paroxetine 20 mg a day.
7. Atripla one at night.
9. Blood pressure medicine, name unknown.
REVIEW OF SYSTEMS: He otherwise has a negative review of systems.
VITAL SIGNS: Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.) HEENT: Unremarkable except for some submandibular lymph nodes. His fundi are benign. NECK: Supple. LUNGS: Clear to auscultation and percussion. CARDIAC: Reveals regular rate and rhythm without murmur, rub or gallop. ABDOMEN: Soft and nontender without organomegaly or mass. EXTREMITIES: Show no cyanosis, clubbing or edema. GU: Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.
1. Human immunodeficiency virus disease with stable control on Atripla.
3. Diabetes mellitus, currently on oral therapy.
6. Chronic musculoskeletal pain of unclear etiology.
PLAN: The patient will continue his current medications. He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter. He has been encouraged to keep his appointment with his psychologist.
Keywords: soap / chart / progress notes, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension,