Medical Specialty:
SOAP / Chart / Progress Notes

Sample Name: Gen Med Progress Note - 3

Description: Sample progress note - Gen Med.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis.

SUBJECTIVE: A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly.


MEDICATIONS: Refer to chart.

ALLERGIES: Refer to chart.

Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.
General: A 70-year-old female who does not appear to be in acute distress.
HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull.
Neck: Supple.
Heart: Clear.
Lungs: Clear.
Abdomen: Large, nontender. No swelling.

1. Hypercholesterolemia.
2. Diabetes mellitus.
3. Sinusitis.

1. Allegra D 1 p.o. b.i.d. x 3 days.
2. Allegra 180 mg daily x 7 days.
3. Check an A1c, BMP, lipid profile, TSH.
4. She was given a copy of Partners in Prevention.
5. We discussed colonoscopy, and she is not ready to do that right now.
6. Will check stools for occult blood x 3. She is aware that a colonoscopy could pick up an early cancer.
7. Diet, exercise, weight loss stressed. We will let her know the results of her tests.
8. Refilled her prescriptions x 6 months.

Keywords: soap / chart / progress notes, diabetes mellitus, accu-cheks, sinusitis, abdominal pain, constipation, diarrhea, general medicine, hypercholesterolemia, nausea, progress note, vomiting, weight loss, colonoscopy, diabetes,