SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 2
Description: Sample progress note - Gen Med.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Followup on hypertension and hypercholesterolemia.
SUBJECTIVE: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson. He is known to have Crohn's and he takes care of that for him. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles.
MEDICATIONS: Refer to chart.
ALLERGIES: Refer to chart.
Vitals: Wt; 172 lbs, up 2 lbs, B/P; 150/60, T; 96.4, P; 72 and regular.
General: A 78-year-old male who does not appear to be in any acute distress. Glasses. Good dentition.
Lungs: Diminished with increased AP diameter.
Abdomen: Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.
Extremities: Well-healed surgical scar on the right knee. No edema. Hand grasps are strong and equal.
Back: Surgical scar on the lower back.
Neuro: Intact. A&O. Moves all four with no focal motor or sensory deficits.
PLAN: We will check a BMP, lipid, liver profile, CPK, and CBC. Refill his medications x 3 months. I gave him a copy of Partners in Prevention. Increase his Altace to 5 mg day for better blood pressure control. Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.
Keywords: soap / chart / progress notes, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, general medicine, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress,