SOAP / Chart / Progress Notes
Sample Name: Refractory Hypertension - Followup
Description: Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.
(Medical Transcription Sample Report)
1. Refractory hypertension, much improved.
2. History of cardiac arrhythmia and history of pacemaker secondary to AV block.
3. History of GI bleed in 1995.
4. History of depression.
HISTORY OF PRESENT ILLNESS: This is a return visit to the renal clinic for this patient. She is an 85-year-old woman with history as noted above. Her last visit was approximately four months ago. Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously. She is not reporting any untoward side effect. She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. She has no orthopnea. Her exercise capacity is about the same. The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. No history of extremity pain.
1. Triamterene/hydrochlorothiazide 37.5/25 mg.
3. Atenolol 50 mg a day.
4. Atacand 32 mg a day.
5. Cardura 4 mg a day.
VITAL SIGNS: Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. THORAX: Revealed lungs that are clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3. I could not hear murmur today. ABDOMEN: Above plane, but nontender. EXTREMITIES: Revealed no edema.
ASSESSMENT: This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.
Keywords: soap / chart / progress notes, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia,