SOAP / Chart / Progress Notes
Sample Name: Cardiology Progress Note
Description: Problem of essential hypertension. Symptoms that suggested intracranial pathology.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is a 78-year-old female with the problem of essential hypertension. She has symptoms that suggested intracranial pathology, but so far work-up has been negative.
She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure. She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.
OBJECTIVE: Heart rate is 80 and blood pressure is 130/70. Head and neck are unremarkable. Heart sounds are normal. Abdomen is benign. Extremities are without edema.
ASSESSMENT AND PLAN: The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past. I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc. So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4. In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.
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