SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 9
Description: Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in the morning when she is up, but then through the day it begins to swell again. Lately it is staying bigger and she somewhat uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. The other problem she had was she has had pain in her shoulder and back. These occurred about a year ago, but the pain in her left shoulder is of most concern to her. She feels like the low back pain is just a result of a poor mattress. She does not remember hurting her shoulder, but she said gradually she has lost some mobility. It is hard time to get her hands behind her back or behind her head. She has lost strength in the left shoulder. As far as the blood count goes, she had an elevated white count. In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up. She also complains of a lot of frequency with urination and nocturia times two to three. She has gained weight; she thinks about 12 pounds since March. She now weighs 284. Fortunately, her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much. She denies chest pain, but she does feel like she is becoming gradually more short of breath. She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much. Towards the end of the day her leg was really swollen. I reviewed her lab work. Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.
General: The patient is a very pleasant 44-year-old white female quite obese.
Vital Signs: Blood pressure: 122/70. Temperature: 98.6.
HEENT: Head: Normocephalic. Ears: TMs intact. Eyes: Pupils round, and equal. Nose: Mucosa normal. Throat: Mucosa normal.
Heart: Regular rate and rhythm.
Abdomen: Soft and obese.
Extremities: A lot of fluid in both legs, but especially the left leg is really swollen. At least 2+ pedal edema. The right leg just has a trace of edema. She has pain in her low back with range of motion. She has a lot of pain in her left shoulder with range of motion. It is hard for her to get her hand behind her back. She cannot get it up behind her head. She has pain in the anterior left shoulder in that area.
1. Multiple problems including left leg swelling.
2. History of leukocytosis.
3. Joint pain involving the left shoulder, probably impingement syndrome.
4. Low back pain, chronic with obesity.
6. Frequency with urination.
7. Tobacco abuse.
1. I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel. We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.
2. Elevate her leg as much as possible and wear support hose if possible. Keep her foot up during the day. We will see her back in two weeks. We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain. If her shoulder pain is not any better, we probably should refer her on over to orthopedist. We did do x-rays of her shoulder today that did not show anything remarkable. See her in two weeks or p.r.n.
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