SOAP / Chart / Progress Notes
Sample Name: HIV Followup - 1
Description: Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.
(Medical Transcription Sample Report)
1. HIV stable.
2. Hepatitis C chronic.
3. History of depression, stable off meds.
4. Hypertension, moderately controlled.
CHIEF COMPLAINT: The patient comes for a routine followup appointment.
HISTORY OF PRESENTING ILLNESS: This is a 34-year-old African American female who comes today for routine followup. She has no acute complaints. She reports that she has a muscle sprain on her upper back from lifting. The patient is a housekeeper by profession. It does not impede her work in anyway. She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication. No other associated complaints. No neurological deficits or other specific problems. The patient denies any symptoms associated with opportunistic infection.
1. Significant for HIV.
1. She is on Trizivir 1 tablet p.o. b.i.d.
2. Ibuprofen over-the-counter p.r.n.
ALLERGIES: She has no known drug allergies.
DRUG INTOLERANCE: There is no known drug intolerance in the past.
NUTRITIONAL STATUS: The patient eats regular diet and eats 3 meals a day.
REVIEW OF SYSTEMS: Noncontributory except as mentioned in the HPI.
RADIOLOGICAL DATA: She has had no recent radiological procedures.
SEXUAL HISTORY: She has had no recent STDs and she is not currently sexually active. PPD status was negative in the past. PPD will be placed again today.
Treatment adherence counseling was performed by both nursing staff and myself. Again, the patient is a 100% compliant with her meds. Last dental exam was in 11/07, where she had 2 teeth extracted. Last Pap smear was 1 year ago was negative. The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram. She has no family history of breast cancer.
ADVANCED DIRECTIVE: Unknown.
GENERAL: This is a thinly built female, not in acute distress. VITAL SIGNS: Temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds. HEAD AND NECK: Reveals bilaterally reactive pupils. Supple neck. No thrush. No adenopathy. HEART: Heart sounds S1 and S2 regular. No murmur. LUNGS: Clear bilaterally to auscultation. ABDOMEN: Soft and nontender with good bowel sounds. NEUROLOGIC: She is alert and oriented x3 with no focal neurological deficit. EXTREMITIES: Peripheral pulses are felt bilaterally. She has no pitting pedal edema, clubbing or cyanosis. GU: Examination of external genitalia is unremarkable. There are no lesions.
LABORATORY DATA: From 11/07 shows hemoglobin and hematocrit of 16 and 46. Creatinine of 0.6. LFTs within normal limits. Viral load of less than 48 and CD4 count of 918.
2. Hepatitis C with stable transaminases.
3. History of depression, stable off meds.
4. Hypertension, moderately controlled on meds.
PLAN: Continue her current meds. I have discussed with her in the past about possibility of having to change off of her Trizivir in the future. If she develops resistance since triple NRTI therapy is not the preferred, but she is not amenable to that at this time. She has excellent viremic control and good CD4 count. We will readdress this with her in the future if her status changes. The patient is to have PPD placed today as well to schedule for annual Pap smear. She has received her annual influenza vaccination for this season. She will be re-seen by the dental clinic for routine evaluation and have labs today including CD4, viral load, RPR, and urinalysis. She is to be prescribed Ultram for a 7-day course p.r.n. use b.i.d. for the muscle sprain. She will return to our clinic in 6 months. The patient does not want to be seen more often since she has a job that she reports to and cannot miss more days off work. Again this is acceptable since she has excellent viremic control. The patient has been educated regarding her meds and plan. Her prognosis is excellent and she will follow up with us in 6 months.
Keywords: soap / chart / progress notes, hepatitis, hypertension, trizivir, human immunodeficiency virus, hiv, immunodeficiency,