SOAP / Chart / Progress Notes
Sample Name: Down's syndrome
Description: A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.
(Medical Transcription Sample Report)
SUBJECTIVE: This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April, I also found that he was hypothyroid with elevated TSH. He was started on Levothroid 0.1 mg and has been taking that daily. We will recheck a TSH today as well. His mother notes that although he does not like to take the medications, he is taking it with encouragement. His only other medications are some eyedrops for his cornea.
OBJECTIVE: Weight was 149 pounds, which is up 2 pounds. Blood pressure was 120/80. Pulse is 80 and regular.
Neck: Supple without adenopathy. No thyromegaly or nodules were palpable.
Cardiac: Regular rate and rhythm without murmurs.
Skin: Examination of the toenails showed really no change yet. They are still quite thickened and yellowed.
1. Down’s syndrome.
1. Recheck ALT and TSH today and call results.
2. Lamisil 250 mg #30 one p.o. daily with one refill. They will complete the next eight weeks of therapy as long as the ALT is normal. I again reviewed the symptoms of liver dysfunction.
3. Continue Levothroid 0.1 mg daily unless dosage need to be adjusted based on the TSH.
Keywords: soap / chart / progress notes, down’s syndrome, hypothyroidism, onychomycosis, hypothyroid, tsh, down’s,