SOAP / Chart / Progress Notes
Sample Name: Weight Loss on Phentermine
Description: Followup on weight loss on phentermine.
(Medical Transcription Sample Report)
SUBJECTIVE: She is here for a followup on her weight loss on phentermine. She has gained another pound since she was here last. We talked at length about the continued plateau she has had with her weight. She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136. She is frustrated with this as well. We agree that if she continues to plateau she really should not stay on phentermine. We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees.
REVIEW OF SYSTEMS: Otherwise negative. She has no specific complaints. No shortness of breath, chest pain or palpitations.
Vital signs: Her blood pressure is fine. Her diastolic is a little bit high, but otherwise okay.
General: She appears in good spirits. No apparent distress.
Neck: Supple without bruits.
ASSESSMENT: Weight loss on phentermine, really has plateaued.
PLAN: If she does not lose weight in the next month we will probably consider having her go off the phentermine. If she does lose a couple of pounds, then we will keep her on it until she gets closer to her goal of 135 and then try to keep her there for one or two months and then stop. She agrees with this plan.
Keywords: soap / chart / progress notes, followup, phentermine, plateau, weight, weight loss, weight loss on phentermine, loss,