Medical Specialty:
SOAP / Chart / Progress Notes

Sample Name: Chronic Kidney Disease Followup - 1

Description: Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.
(Medical Transcription Sample Report)

1. Type 1 diabetes mellitus, insulin pump requiring.
2. Chronic kidney disease, stage III.
3. Sweet syndrome.
4. Hypertension.
5. Dyslipidemia.
6. Osteoporosis.
7. Anemia.
8. A 25-hydroxy-vitamin D deficiency.
9. Peripheral neuropathy manifested by insensate feet.
10. Hypothyroidism.
11. Diabetic retinopathy.

HISTORY OF PRESENT ILLNESS: This is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management. Her last visit to this clinic was approximately three months ago. Since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses. She did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management. Her 14-day average is 191. She had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low. She was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100. She was able to manage this completely on her own. In the meantime, she is not having any other medical problems that have interfered with glucose control. Her diet has been a little bit different in that she had been away visiting with her family for some period of time as well.

1. A number of topical creams for her rash.
2. Hydroxyzine 25 mg 4 times a day.
3. Claritin 5 mg a day.
4. Fluoxetine 20 mg a day.
5. Ergocalciferol 800 international units a day.
6. Protonix 40 mg a day.
7. Iron sulfate 1.2 cc every day.
8. Actonel 35 mg once a week.
9. Zantac 150 mg daily.
10. Calcium carbonate 500 mg 3 times a day.
11. NovoLog insulin via insulin pump about 30 units of insulin daily.
12. Zocor 40 mg a day.
13. Valsartan 80 mg daily.
14. Amlodipine 5 mg a day.
15. Plavix 75 mg a day.
16. Aspirin 81 mg a day.
17. Lasix 20 mg a day.
18. Levothyroxine 75 micrograms a day.

REVIEW OF SYSTEMS: Really not much change. Her upper respiratory symptoms have resolved. She is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain. She is not having any decreased appetite. She is not having painful urination, any blood in the urine, frequency or hesitancy. She is not having polyuria, polydipsia or polyphagia. Her visual acuity has declined, but she does not appear to have any acute change.

VITAL SIGNS: Temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds. HEENT: Examination found her to be atraumatic and normocephalic. She has pupils that are equal, round, and reactive to light. Extraocular muscles intact. Sclerae and conjunctivae are clear. The paranasal sinuses are nontender. The nose is patent. The external auditory canal and tympanic membranes are clear A.U. Oral cavity and oropharynx examination is free of lesions. The mucosus membranes are moist. NECK: Supple. There is no lymphadenopathy. There is no thyromegaly. THORAX: Reveals lungs that are clear, PA and lateral, without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. EXTREMITIES: Reveal no edema and is otherwise deferred.

ASSESSMENT AND PLAN: This is a return visit to the renal clinic for the patient with history as noted above. She has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following: Basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour. Her target pre-meal is 120 and bedtime is 150. Her insulin/carbohydrate ratio is 10 and her correction factor is 60. We are not going to make any changes to her insulin pump settings at this time. I have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night. She has agreed to try that and cut back on this a little bit. I want to get fasting labs to include her standard labs for us today but include a fasting C-peptide and a hemoglobin A1C, so that we can make arrangements for her to get an upgraded insulin pump. She states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time. Nonetheless, she is out of warranty and we will try to get her a new pump.

Plan to see the patient back here in approximately two months, and we will try to get the new pump through Medicare.

Keywords: soap / chart / progress notes, chronic kidney disease, diabetes mellitus, renal clinic, glucose control, blood sugar, insulin pump, insulin, kidney, peripheral, glucose,