SOAP / Chart / Progress Notes
Sample Name: Leg Pain & Bone Pain
Description: A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Leg pain.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionally. She has had a little bit of fever and nausea. She has noticed her blood sugars have been low. She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita. She has noticed her fasting blood sugars have been ranging from 100 to 120. Blood sugars one and a half hours after meals have been 185. She is coming in for a diabetic checkup in one month and wants lab prior to that time. She has been eating more meat recently and has not been on a diet for cholesterol.
CURRENT MEDICATIONS: Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d., Maxzide 37/25 q.d., Protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d.
ALLERGIES: Cipro, sulfa, Bactrim, and Demerol.
Vital Signs: Weight is 248 pounds which is a 12-pound drop from January. Blood pressure 120/70. Pulse 68.
HEENT: Oropharynx and HEENT are within normal limits.
Heart: Regular rhythm and rate.
Abdomen: Soft, nontender, and nondistended without organomegaly.
GU: Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.
Neurologic: Deep tendon reflexes are normal.
Extremities: Pulses in lower extremities are normal. Straight leg lifts are normal.
2. Hypercholesterolemia, this is somewhat bothersome as she is a diabetic. Did discuss with her that we need to stick to the diet especially after going off of Lipitor. We will see how she does with her bone pain/leg pain off of Lipitor. If she has improvement may consider Crestor in one month. I am going to check her lipid panel and a CMP. Apparently, she is going to get this at a different site, Mapleridge in Wichita.
3. Type II diabetes. We will decrease her Glucovance because she is having frequent low blood sugars. Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms. I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment.
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