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.
PAST MEDICAL HISTORY: Refer to chart.
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.
Abdomen: Large, nontender. No swelling.
2. Diabetes mellitus.
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.
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,