SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 8
Description: Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is an 89-year-old lady. She actually turns 90 later this month, seen today for a short-term followup. Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended. She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily. She thinks, she also has an element of office hypertension. Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka. However, when we gave her samples of that she thought they were too big for her to swallow. Basically, she is just back on her previous blood pressure regimen. However, her blood pressure seems to be better today. Her daughter says that they do check it periodically and it is similar to today’s reading. Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade. We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems. She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve. She takes Tylenol p.r.n., which seems to be enough for her. She does not think she has any acid reflux symptoms or heartburn. She does take Tums t.i.d. and also Mylanta at night. She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth. They do heal up, but then she will get another one. She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor. They do think the Lexapro has helped to some extent.
MEDICATION: Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.
REVIEW OF SYSTEMS: Mostly otherwise as above.
General: She is a pleasant elderly lady. She is in no acute distress, accompanied by daughter.
HEENT: No acute changes. Atraumatic, normocephalic. On mouth exam, she does have dentures. She removed her upper denture. I really do not see any sores at all. Her mouth exam was unremarkable.
Neck: No adenopathy, tenderness, JVD, bruits, or mass.
Heart: Regular rate and rhythm.
Extremities: No significant edema. Reasonable pulses. No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable. No other focal or neurological deficits grossly.
1. Hypertension, better reading today.
2. Right arm symptoms, resolved.
4. Perhaps a very subtle tremor. I will just watch that.
PLAN: I think I will just watch everything for now. I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half. I offered to see her for again short-term followup. However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner. She might get a flu shot here in the next few weeks. Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.
Keywords: soap / chart / progress notes, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose,