SOAP / Chart / Progress Notes
Sample Name: Multiple Medical Problems
Description: Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.)
(Medical Transcription Sample Report)
SUBJECTIVE: The patient was seen today by me at Nursing Home for her multiple medical problems. The nurses report that she has been confused at times, having incontinent stool in the sink one time but generally she does not do that poorly. She does have trouble walking which she attributes to weak legs. She fell a couple of months ago. Her eating has been fair. She has been losing weight a little bit. She denies diarrhea. She does complain of feeling listless and unambitious and would like to try some Ensure.
CURRENT MEDICATIONS: Her meds are fairly extensive and include B12 1000 mg IM monthly, Digitek 250 p.o. every other day alternating with 125 mcg p.o. every other day, aspirin 81 mg daily, Theragran-M daily, Toprol XL 25 mg daily, vitamin B6 100 mg daily, Prevacid 30 mg daily, Oyster Shell calcium with D 500 mg t.i.d., Aricept 5 mg daily, Tylenol 650 mg q.4h. p.r.n., furosemide 20 mg daily p.r.n., and sublingual Nitro p.r.n., and alprazolam 0.25 mg p.r.n.
ALLERGIES: Sulfa and trimethoprim.
General: She is a well-developed, well-nourished, elderly female in no acute distress.
Vital Signs: Her age is 90. Temperature is 98.5 degrees. Blood pressure: 100/54. Pulse: 60. Respirations: 18. Weight was 132.6 about a week ago, which is down one pound from couple of months ago.
HEENT: Head was normocephalic.
Heart: Regular rate and rhythm.
Abdomen: Soft, nontender without hepatosplenomegaly or mass.
Extremities: No calf tenderness or significant ankle edema x 2 in the lower extremities is noted.
Mental Status Exam: She was uncertain what season we are in. She thought we were almost in winter. She did know that today of the week was Friday. She seemed to recognize me.
1. Alzheimer’s dementia.
2. Gradual weight loss.
4. B12 deficiency.
PLAN: I ordered yearly digoxin levels. Increased her Aricept to 10 mg daily. She apparently does have intermittent atrial fibrillation as a reason for being on the digoxin. We will plan to recheck her in a couple of months. Ordered health supplement to be offered after each meal due to her weight loss.
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