Medical Specialty:
SOAP / Chart / Progress Notes

Sample Name: Nephrolithiasis - Progress Note

Description: Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.
(Medical Transcription Sample Report)

SUBJECTIVE: The patient returns today for a followup. She was recently in the hospital and was found to be septic from nephrolithiasis. This was all treated. She did require a stent in the left ureter. Dr. XYZ took care of this. She had a stone, which was treated with lithotripsy. She is now back here for followup. I had written out all of her medications with their dose and schedule on a progress sheet. I had given her instructions regarding follow up here and follow with Dr. F. Unfortunately, that piece of paper was lost. Somehow between the hospital and home she lost it and has not been able to find it. She has no followup appointment with Dr. F. The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc. Later she apparently found the prescriptions and they were filled. She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take. She had no clue as to seeing Dr. XYZ again. She says she is still not feeling very well and feels somewhat sick like. She has no clue as to still having a ureteral stent. I explained this to she and her husband again today.


CURRENT MEDICATIONS: As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.

REVIEW OF SYSTEMS: She says she is voiding okay. She denies fever, chills, or sweats.

General: She was able to get up on the table by herself although she is quite unstable.
Vital Signs: Blood pressure was okay at about 120/70 by me.
Neck: Supple.
Lungs: Clear.
Heart: Regular rate and rhythm.
Abdomen: Soft.
Extremities: There is no edema.

1. Hypertension controlled.
2. Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.
3. Urinary incontinence.
4. Recent sepsis.

1. I discussed at length with she and her husband again the need to get into at least an assisted living apartment.
2. I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.
3. See me back here in two months.
4. I made no changes in her medications.

Keywords: soap / chart / progress notes, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications,