Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Polycythemia Vera Followup

DIAGNOSIS:,  Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  Diagnosis was made some time in 2005/2006.  Initially, he underwent phlebotomy.  He subsequently transferred his care here.  In the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  He is JAK-2 positive.  He does not have any siblings for a match-related transplant.  He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period.  He did well with the combination.  Subsequently, he developed intolerance to lenalidomide.  He complained of severe fatigue and diarrhea.  This was subsequently stopped.,The patient reports some injury to his left leg last week.  His left leg apparently was swollen.  He took steroids for about 3 days and stopped.  Left leg swelling has disappeared.  The patient denies any other complaints at this point in time.  He admits to smoking marijuana.  He says this gives him a great appetite and he has actually gained some weight.  Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  GENERAL:  He is in no acute distress.  HEENT:  There is no pallor, icterus or cervical adenopathy that is noted.  Oral cavity is normal to exam.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  ABDOMEN:  Soft and nontender with no hepatomegaly.  Spleen is palpable 4 fingerbreadths below the left costal margin.  There is no guarding, tenderness, rebound or rigidity noted.  Bowel sounds are present.  EXTREMITIES:  Reveal no edema.  Palpation of the left tibia revealed some mild tenderness.  However, I do not palpate any bony abnormalities.  There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1.  JAK-2 positive myeloproliferative disorder.  The patient has failed pretty much all available options.  He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial.  Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2.  I am concerned about the risk of thrombosis with his elevated white count.  He is on aspirin prophylaxis.  The patient has been told to call me with any complaints.,3.  Left shin pain.  I have ordered x-rays of the left tibia and knee today.  The patient will return to the clinic in 3 weeks.  He is to call me in the interim for any problems.
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DESCRIPTION: Followup for polycythemia vera with secondary myelofibrosis.  JAK-2 positive myeloproliferative disorder.   He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.

soap / chart / progress notes, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis,

The scenario involves a follow-up appointment for a patient with polycythemia vera and secondary myelofibrosis, a serious medical condition. The patient has a complex medical history and limited treatment options, which raises the stakes due to the potential for disease progression and complications such as thrombosis. The physician is considering a clinical trial for further treatment, indicating the significance of the disease management. Although it's a follow-up, the stakes are high as the patient's future health and quality of life are significantly affected by the management decisions made at this visit.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Ophthalmology Progress Note - 1

She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.
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DESCRIPTION: Ophthalmology followup visit note.

Ophthalmology followup visit note.

soap / chart / progress notes, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, ophthalmology, acuitiesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The note indicates that the patient is stable and does not require any immediate intervention. The mention of a follow-up in six months suggests routine monitoring, with the option to return sooner if there are changes in her vision. This suggests that the situation is currently stable with low risk and typical follow-up care.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Nephrolithiasis - Progress Note

SUBJECTIVE:,  The patient returns today for a followup.  She was recently in the hospital and was found to be septic from nephrolithiasis.  This was all treated.  She did require a stent in the left ureter.  Dr. XYZ took care of this.  She had a stone, which was treated with lithotripsy.  She is now back here for followup.  I had written out all of her medications with their dose and schedule on a progress sheet.  I had given her instructions regarding follow up here and follow with Dr. F.  Unfortunately, that piece of paper was lost.  Somehow between the hospital and home she lost it and has not been able to find it.  She has no followup appointment with Dr. F.  The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc.  Later she apparently found the prescriptions and they were filled.  She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take.  She had no clue as to seeing Dr. XYZ again.  She says she is still not feeling very well and feels somewhat sick like.  She has no clue as to still having a ureteral stent.  I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:,  As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:,  She says she is voiding okay.  She denies fever, chills, or sweats.,OBJECTIVE:,General:  She was able to get up on the table by herself although she is quite unstable.,Vital Signs:  Blood pressure was okay at about 120/70 by me.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  There is no edema.,IMPRESSION:,1.  Hypertension controlled.,2.  Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3.  Urinary incontinence.,4.  Recent sepsis.,PLAN:,1.  I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2.  I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3.  See me back here in two months.,4.  I made no changes in her medications.
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DESCRIPTION: Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.

soap / chart / progress notes, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications,

This situation involves a follow-up for a patient recently treated for septic nephrolithiasis, a potentially life-threatening condition that required hospital admission. The patient had multiple complications, including a stent placement and a history of urinary incontinence. Despite treatment, there are still uncertainties, like confusion about the follow-up, medication schedule, and her awareness of the stent. These factors suggest incomplete resolution of the medical issues and the need for careful management. The stakes involve the patient's health and risk of future complications if not monitored closely.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Obesity Hypoventilation Syndrome

HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep.  She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep.",MEDICATIONS: , Current medications are as previously noted.  Changes include reduction in prednisone from 9 to 6 mg by mouth every morning.  She continues to take Ativan 1 mg every six hours as needed.  She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs:  Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest.  Chest is clear.  Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used.  She used it for greater than 4 hours per night on 67% of night surveyed.  Her estimated apnea/hypopnea index was 3 per hour.  Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy.  She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%).  Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour.  Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%.  During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1.  Obesity hypoventilation syndrome.  The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity.  In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2.  Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute.  The breathing pattern is that of cluster or Biot's breathing throughout sleep.  The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3.  Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4.  Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep.  These will include, (1).  Decrease in evening doses of MS Contin, (2).  Modest weight loss of approximately 10 to 20 pounds, and (3).  Instituting Automated Servo Ventilation via nasal mask.  With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements.  I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed.  I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time.  She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation.  Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.
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DESCRIPTION: Obesity hypoventilation syndrome.  A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.

soap / chart / progress notes, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity,

The situation described involves a complex medical condition with multiple interrelated health issues that require careful management. The patient has obesity hypoventilation syndrome, severe central sleep apnea exacerbated by opiate use, and other related health concerns. These are significant health issues that can affect the patient's quality of life and, if not managed properly, can lead to serious complications, including respiratory distress and cardiovascular issues. Therefore, the stakes are relatively high, as proper treatment and management are crucial for maintaining the patient's health.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Lung Biopsy Discussion

CHART NOTE:,  She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  Dr. XYZ had seen her because of her complaints of shortness of breath.  Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep.  He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  She was ready to go ahead with this and felt that it was important she find out why she is short of breath.  She is very concerned about the findings on her CAT scan and pulmonary function test.  She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal.  However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function.  And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests.  And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing.  We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  I told her I would try to talk to her sister sometime in the next day or two.
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DESCRIPTION: Patient is here to discuss possible open lung biopsy.

soap / chart / progress notes, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a significant medical procedure, an open lung biopsy, which is invasive and poses inherent risks to the patient. The discussion includes the understanding of potential outcomes and risks without substantial benefits in this context. The stakes are moderate to high due to the medical nature and the decision-making process involved, which could significantly impact the patient's health and well-being. However, as the procedure was ultimately canceled in favor of monitoring, it slightly reduces the immediate high-stakes nature.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Lap Band Adjustment

REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,
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DESCRIPTION: Patient status post lap band placement.

Patient status post lap band placement.

soap / chart / progress notes, lap band adjustment, lap band placement, lap band,

The situation involves a medical procedure related to the adjustment of a lap band, which is used for weight management in individuals with obesity. While the procedure itself is relatively routine for patients with lap bands, the patient's recent history, including a car accident and issues with hunger and satiety, could complicate the situation slightly. These factors, in conjunction with the patient's stress and the need for regular follow-ups, add some level of complexity. However, the procedure itself was performed without complications, and the patient is doing well post-procedure. Overall, this is not an emergency or life-threatening scenario, and is a routine follow-up in obesity management.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Laminectomy & Foraminotomy Followup

REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was "restless leg syndrome" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.
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DESCRIPTION: Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.

soap / chart / progress notes, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine,

The situation involves the follow-up of a patient post-surgery involving spinal operations like laminectomy, foraminotomies, and spinal fusion. These are significant medical procedures, and the follow-up is crucial to ensure that there are no complications such as hardware malposition, persistent pain, or infection. Although the patient's situation seems stable with improvement in symptoms, there is mention of a fluid collection and cautious avoidance of interventional pain management to minimize infection risk. The stakes are moderate to high due to the potential impact on the patient's recovery and quality of life, but not at the level of a critical emergency.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Hypertension - Progress Note

SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.
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DESCRIPTION: Patient with hypertension, syncope, and spinal stenosis - for recheck.

soap / chart / progress notes, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea,

The progress note describes the follow-up of an elderly patient with a history of hypertension, syncope, and spinal stenosis. While hypertension is a common condition, it requires ongoing management to prevent complications. Syncope, especially in the context of cardiac history, requires careful monitoring to rule out serious underlying conditions. Additionally, the patient is being evaluated for spinal stenosis, which might lead to surgery, posing potential surgical risks. The situation involves a mix of chronic and acute concerns, particularly given the age of the patient and her family history of cardiac issues. Therefore, it represents a moderate to high-stakes medical situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 9

SUBJECTIVE:  ,This patient presents to the office today for a checkup.  He has several things to go over and discuss.  First he is sick.  He has been sick for a month intermittently, but over the last couple of weeks it is worse.  He is having a lot of yellow phlegm when he coughs.  It feels likes it is in his chest.  He has been taking Allegra-D intermittently, but he is almost out and he needs a refill.  The second problem, his foot continues to breakout.  It seems like it was getting a lot better and now it is bad again.  He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream.  I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence.  He works in the flint and it is really hot where he works and it has been quite humid lately.  The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger.  He is interested in getting that frozen today.  Apparently, he tells me I froze a previous wart on him in the past and it went away.  Next, he is interested in getting some blood test done.  He specifically mentions the blood test for his prostate, which I informed him is called the PSA.  He is 50 years old now.  He will also be getting his cholesterol checked again because he has a history of high cholesterol.  He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking.  He says it is difficult to quit.  He tells me he did quit chewing tobacco.  I told him to keep trying to quit smoking.  ,REVIEW OF SYSTEMS:,  General:  With this illness he has had no problems with fever.  HEENT:  Some runny nose, more runny nose than congestion.  Respiratory:  Denies shortness of breath.  Skin:  He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today.  At times it is itchy.,OBJECTIVE: , His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.  Skin exam:  I checked out the bottom of his right foot.  He has peeling skin visible consistent with tinea pedis.  On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart.  The size of this wart is approximately 3 mm in diameter.,ASSESSMENT:  ,1.  Upper respiratory tract infection, persistent.,2.  Tinea pedis.,3.  Wart on the finger.,4.  Hyperlipidemia.,5.  Tobacco abuse.,PLAN: , The patient is getting a refill on Allegra-D.  I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day.  I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work.  His wart has been present for some time now and he would like to get it frozen.  I offered him the liquid nitrogen treatment and he did agree to it.  I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart.  He tolerated the procedure very well.  I froze it once and I allowed for a 3 mm freeze zone.  I gave him verbal wound care instructions after the procedure.  Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test.  Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days.
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DESCRIPTION: Upper respiratory tract infection, persistent.  Tinea pedis.  Wart on the finger.  Hyperlipidemia.  Tobacco abuse.

soap / chart / progress notes, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart,

The scenario presented in the SOAP note involves a variety of common medical issues, including an upper respiratory tract infection, tinea pedis, a wart, hyperlipidemia, and tobacco abuse. While these conditions can affect the patient's quality of life and long-term health if not addressed, they are generally not life-threatening in the short term. The medical practitioner has a plan in place to manage these issues, including medication, treatment procedures, and blood tests. There are no immediate high-risk conditions identified, and the patient is not in acute distress. Therefore, the overall situation does not constitute a high-stakes scenario.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 10

SUBJECTIVE: , The patient has NG tube in place for decompression.  She says she is feeling a bit better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Pulse is 58 and blood pressure is 110/56.,SKIN:  There is good skin turgor.,GENERAL:  She is not in acute distress.,CHEST:  Clear to auscultation.  There is good air movement bilaterally.,CARDIOVASCULAR:  First and second sounds are heard.  No murmurs appreciated.,ABDOMEN:  Less distended.  Bowel sounds are absent.,EXTREMITIES:  She has 3+ pedal swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA:,  White count is down from 20,000 to 12.5, hemoglobin is 12, hematocrit 37, and platelets 199,000.  Glucose is 157, BUN 14, creatinine 0.6, sodium is 131, potassium is 4.0, and CO2 is 31.,ASSESSMENT AND PLAN:,1.  Small bowel obstruction/paralytic ileus, rule out obstipation.  Continue with less aggressive decompression.  Follow surgeon's recommendation.,2.  Pulmonary fibrosis, status post biopsy.  Manage as per pulmonologist.,3.  Leukocytosis, improving.  Continue current antibiotics.,4.  Bilateral pedal swelling.  Ultrasound of the lower extremity negative for DVT.,5.  Hyponatremia, improving.,6.  DVT prophylaxis.,7.  GI prophylaxis.
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DESCRIPTION: The patient has NG tube in place for decompression.

soap / chart / progress notes, small bowel obstruction, paralytic ileus, decompression, ng tube, pedal swelling, prophylaxis

The patient's condition involves a small bowel obstruction/paralytic ileus, potential complications related to pulmonary fibrosis, leukocytosis, and hyponatremia. However, the patient is showing signs of improvement (e.g., leukocytosis improving, hyponatremia improving) and is not in acute distress. Despite these improvements, conditions like small bowel obstruction can be serious and require ongoing careful management and monitoring, meaning that the situation needs attention but is not life-threatening at the moment when assessed by the medical team.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 5

S:,  The patient is here today with his mom for several complaints.  Number one, he has been having issues with his right shoulder.  Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder.  He has been having issues ever since.  He is having difficulties raising his arm over his head.  He does have some intermittent numbness in his fingers at night.  He is not taking any anti-inflammatories or pain relievers.  He is also complaining of a sore throat.  He did have some exposure to Strep and he has a long history of strep throat.  Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation.  He is also being seen for ADHD by Dr. B.  Adderall and Zoloft.  He takes these once a day.  He does notice when he does not take his medication.  He is doing well in school.  He is socializing well.  He is maintaining his weight and tolerating the medications.  However, he is having issues with anger control.  He realizes when he has anger outbursts that it is a problem.  His mom is concerned.  He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:,  Reviewed and unchanged.,O:,  VSS.  In general, patient is A&Ox3.  NAD.  Heart:  RRR.  Lungs:  CTA.  HEENT:  Unremarkable.  He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip.  Musculoskeletal:  Limited in range of motion, active on the right.  He stops at about 95 degrees.  No muscle weakness.  Neurovascularly intact.  Negative biceps tenderness.  Psych:  No suicidal, homicidal ideations.  Answering questions appropriately.  No hallucinations.
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DESCRIPTION: General Medicine SOAP note.  Patient with shoulder bursitis, pharyngitis, attention deficit disorder,

soap / chart / progress notes, general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent

The situation here involves a medical evaluation for several health concerns: a musculoskeletal injury (shoulder issue likely due to bursitis), potential pharyngitis due to a history of Strep exposure, and ongoing management of ADHD with medication. The patient is also experiencing psychological symptoms that might require counseling, suggesting a need for further mental health support. While these issues are medically important, they are not immediately life-threatening, though they require timely and appropriate management to prevent complications and improve the patient's quality of life.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 3

S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.
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DESCRIPTION: General Medicine SOAP note.

General Medicine SOAP note.

soap / chart / progress notes, bodyaches, alert and oriented, no acute distress, soap, diarrhea, general medicine, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented,

The given situation involves a patient case that appears to deal with an upper respiratory infection, common bronchitis, or URI. The patient has already been prescribed antibiotics and is being managed with symptomatic treatment. No acute distress or life-threatening conditions are noted in the assessment, and the patient has clear directions for follow-up should symptoms persist or worsen. While all medical situations require some level of attention, this case does not carry immediate high-stakes elements, such as critical or rapidly deteriorating conditions.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP

SUBJECTIVE: , This patient presents to the office today because he has not been feeling well.  He was in for a complete physical on 05/02/2008.  According to the chart, the patient gives a history of feeling bad for about two weeks.  At first he thought it was stress and anxiety and then he became worried it was something else.  He says he is having a lot of palpitations.  He gets a fluttering feeling in his chest.  He has been very tired over two weeks as well.  His job has been really getting to him.  He has been feeling nervous and anxious.  It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain.  These symptoms are not triggered by exertion.  He had similar symptoms about 9 or 10 years ago.  At that time he went through a full workup.  Everything ended up being negative and they gave him something that he took for his nerves and he says that helped.  Unfortunately, he does not remember what it was.  Also over the last three days he has had some intestinal problems.  He has had some intermittent nausea and his stools have been loose.  He has been having some really funny green color to his bowel movements.  There has been no blood in the stool.  He is not having any abdominal pain, just some nausea.  He does not have much of an appetite.  He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  There is no labored breathing.  Psychiatric:  He is alert and oriented times 3.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Eyes:  Pupils equal, round, and reactive to light bilaterally.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.,ASSESSMENT:  ,1.  Palpitations, possibly related to anxiety.,2.  Fatigue.,3.  Loose stools with some green color and also some nausea.  There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks.  He says his work is definitely contributing to some of his symptoms and he feels stressed.  He is leaving for a vacation very soon.  Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him.  My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis.  A 12-lead EKG was performed on him in the office today.  This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news.  I am going to send him to the lab from our office to get the following tests done:  Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray.  Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital.  We were able to squeeze him in.  His appointment is at 8:15 in the morning.  He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck.  I am not going to be here so he is going to see Dr. X.  Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ.  Certainly, if something comes up we may need to postpone his trip.  We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago.  In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety.  I talked about Ativan, how it works.  I talked about the side effects.  I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck.  I took him off of work today and tomorrow so he could rest.
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DESCRIPTION: Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.

soap / chart / progress notes, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety,

The patient's symptoms, namely palpitations and fatigue, might be related to anxiety but also potentially indicate other conditions. The medical team performed an EKG and scheduled additional tests, including a stress test. The patient's immediate health is not in acute distress, and past tests were negative, suggesting no critical underlying condition initially. However, if symptoms were due to a serious issue, it would require prompt attention given the upcoming trip. The situation is moderately concerning due to the need for timely diagnosis before travel.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 3

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.,PHYSICAL EXAMINATION: ,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.
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DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

The situation involves a routine follow-up on chronic conditions such as diabetes, hypercholesterolemia, and sinusitis. The patient is generally well and not in acute distress, which suggests routine management. However, diabetes and other chronic conditions can have serious implications if not managed properly, creating a moderate level of stakes. The vital signs and subjective reports do not indicate immediate severe issues.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Foot Pain - SOAP

SUBJECTIVE:,  This 32-year-old female comes in again still having not got a primary care physician.  She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect.  She says that Project Access is trying to find her a doctor.  She is not currently on Project Access, and so she is here to get something for the pain in her foot.  I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004.  She said she does not have a primary care physician.  She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers.  She has been in here multiple times for different kinds of pain.  This pain she is having is in her foot.  She had surgery on it, and she has plates and screws.  She said she was suppose to see Dr. XYZ about getting some of the hardware out of it.  The appointment was cancelled, and that is why she came here.  It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her.  She did not injure her foot in any way recently.  It is chronically painful.  Every time she does very much exercise it hurts more.  We have x-rayed it in the past.  She has some hardware there.  It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars.  On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar.  They are all old, and the surgery was done over a year ago.  She is walking with a very slight limp.  There is no redness.  No heat.  No swelling of the foot or the ankle.  It is mildly tender around the medial side of the foot just inferior to the medial malleolus.  It is not warm or red.,ASSESSMENT:,  Foot pain.,PLAN:,  She has been in here before.  She seems very pleasant.  Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill.  After she left, I got to thinking about it and looked into her record.  She has been in here multiple times for pain medicine.  She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago.  We called Dr. XYZ office.  Dr. XYZ nurse said that the patient did not have an appointment today.  She has an appointment on June 15, 2004, for a postop check.  They did not tell her they would not see her today because of insurance, so the patient was lying to me.  We will keep that in mind the next time she returns, because she will likely be back.  She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.
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DESCRIPTION: Patient having foot pain.

Patient having foot pain.

soap / chart / progress notes, soap, foot pain, primary care physician, project access, insurance, foot, project, access, care, appointment

The situation involves a patient returning frequently for pain management without a clearly established primary care physician, which raises concerns about potentially inappropriate use of healthcare resources or doctor shopping. However, the immediate medical issue is foot pain, which while chronic, does not appear to be an acute or life-threatening condition based on the information given. The stakes are primarily related to ensuring the patient receives appropriate care while managing potential misuse of opioids. Administrative issues regarding healthcare access are also significant but not life-critical in nature.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gastric Bypass - Preop Eval

REASON FOR VISIT:,  Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3.  Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds.  Abdomen:  Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:,  The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks.  Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection.  Questions regarding hospital course and recovery were addressed.  We will continue on the Medifast diet until the time of surgery and cleared for surgery.
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DESCRIPTION: Preop evaluation regarding gastric bypass surgery.

soap / chart / progress notes, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass,

The situation involves a preoperative evaluation for a gastric bypass surgery. This type of surgery is significant and potentially life-altering, addressing morbid obesity and associated health risks. The stakes are high because surgery involves risks, such as death, embolism, and infection, which were discussed with the patient. However, the current focus is on a routine preoperative evaluation where the patient has been cleared from various health standpoints and has been successful on a preoperative diet. The existence of these risks and the upcoming surgery increase the stakes, but the current stage is one of assessment and not immediate intervention.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Followup Screw Fixation

REASON FOR VISIT:  ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.  He is currently at home and has left nursing home facility.  He states that his pain is well controlled.  He has been working with physical therapy two to three times a week.  He has had no drainage or fever.  He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed.  He has no effusion noted.  His range of motion is 10 to 105 degrees.  He has no pain or crepitance.  On examination of his right foot, he is nontender to palpation of the metatarsal heads.  He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex.  He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.  Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.  These appear to be extraarticular.  They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT:  ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy.  He may be weightbearing as tolerated on his right side.  I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.  I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias.  He said he has had the left thigh for a number of years and has been followed by a neurologist for this.  He states that he has had some right-sided paresthesias now for a number of weeks.  He claims he has no other symptoms of any worsening stenosis.  I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.
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DESCRIPTION: Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.

soap / chart / progress notes, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal

The situation involves a follow-up medical examination four months after surgery and nonoperative fracture management. The patient's condition is stable, with some chronic issues such as spinal stenosis and neuropathy, but there are no immediate life-threatening concerns. The plan involves continued physical therapy and evaluation by a neurologist if symptoms progress, indicating a manageable health situation rather than an acute crisis.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - Weight Reduction

SUBJECTIVE:,  This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.  The patient states that her husband has been diagnosed with high blood cholesterol as well.  She wants some support with some dietary recommendations to assist both of them in healthier eating.  The two of them live alone now, and she is used to cooking for large portions.  She is having a hard time adjusting to preparing food for the two of them.  She would like to do less food preparation, in fact.  She is starting a new job this week.,OBJECTIVE:,  Her reported height is 5 feet 4 inches.  Today’s weight was 170 pounds.  BMI is approximately 29.  A diet history was obtained.  I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well.  Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:,  The patient’s basal energy expenditure is estimated at 1361 calories a day.  Her total calorie requirement for weight maintenance is estimated at 1759 calories a day.  Her diet history reflects that she is making some very healthy food choices on a regular basis.  She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals.  She also is emphasizing lower fat selections.  Her physical activity level is moderate at this time.  She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend.  We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction.  We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well.  We discussed menu selection, as well as food preparation techniques.  The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that.  I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:,  Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk.  Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week.  This translates into a 1200-calorie meal plan.  I encouraged the patient to keep food records in order to better track calories consumed.  I recommended low fat selections and especially those that are lower in saturated fats.  Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well.  This was a one-hour consultation.  I provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.

soap / chart / progress notes, hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food

The situation described in the dietary consult involves a patient looking to manage her hyperlipidemia, hypertension, gastroesophageal reflux disease, and weight reduction through dietary changes. Although these health conditions require attention, the consultation outlines a standard approach to dietary planning and lifestyle changes. The patient and her husband are seeking to make healthier eating choices and manage portion sizes, which are important for their health but not emergency issues. The stakes are moderate because while managing these health conditions is crucial for long-term health, the immediate risk is not as high as in acute or critical scenarios like a heart attack or stroke.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Endometrial Cancer Followup

CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:
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DESCRIPTION: Stage IIIC endometrial cancer.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.  The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.

soap / chart / progress notes, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,

The scenario involves follow-up for a patient with Stage IIIC endometrial cancer who is undergoing adjuvant chemotherapy. Cancer treatment usually represents a high-stakes situation due to the potential impact on the patient's prognosis, quality of life, and overall health outcomes. The case also notes attempts to complete genetic testing, which can influence treatment decisions. The seriousness of the disease and its treatment implications contribute to its high-stakes nature in a healthcare setting.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Erectile Dysfunction - Followup

HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg.  He indicates that he has noticed some mild improvement of his symptoms, with no side effect.  On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes.  No chest pain, no nitroglycerin usage, no fever, no chills.  No dysuria, gross hematuria, fever, chills.  Daytime frequency every three hours, nocturia times 0, good stream.  He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate.  PSA 11.6.  Dr. X's notes are reviewed.,IMPRESSION:  ,1.  Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time.  We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2.  Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate.  The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy.  However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed.  The patient not to use them at the same time.  Will call if any other concern.  In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy.  He declined scheduling this at this time.  All questions answered.
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DESCRIPTION: Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.

soap / chart / progress notes, improvement of erectile dysfunction, erectile dysfunction, erectile, dysfunction, cialis, psa, biopsy,

The follow-up note discusses a medical check-up for a patient with erectile dysfunction and elevated PSA, suggesting potential prostate issues. The situation involves a decision about medication adjustment and potential further testing, which are routine concerns in medical practice. The stakes here are moderate because while the patient is managing erectile dysfunction and a high-grade PIN (precursor to potential prostate cancer), he is not experiencing immediate health crises or side effects from medication that require urgent intervention. The patient is being monitored actively, and further investigative steps are in discussion, reducing the immediacy of high stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - Hyperlipidemia

SUBJECTIVE:,  This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome.  The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it.  She is not sure that she was following it accurately.  She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well.  Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off.  However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:,  Weight is 275 pounds.  Food records were reviewed.,ASSESSMENT:,  The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago.  I did carefully review her food records and evaluated calories consumed.  While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected.  Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well.  She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates.  While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction.  We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:,  A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat.  This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack.  This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack.  We have eliminated the morning snack.  The patient will now track the grams of fat in her meats as well as added fats.  Her goal for total fats over the course of the day is no more than 42 grams of fat per day.  This was a half hour consultation.  We will plan to see the patient back in one month for support.
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DESCRIPTION: Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

soap / chart / progress notes, hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight

The situation involves a follow-up dietary consultation focusing on managing hyperlipidemia, hypertension, and possible metabolic syndrome through diet. While these conditions can have long-term health impacts, the described consultation and treatment adjustments do not indicate an immediate life-threatening or crisis situation. The stakes pertain to ongoing management and lifestyle adjustments rather than urgent medical intervention.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - Gestational Diabetes

SUBJECTIVE:,  This is a 38-year-old female who comes for dietary consultation for gestational diabetes.  Patient reports that she is scared to eat because of its impact on her blood sugars.  She is actually trying not to eat while she is working third shift at Wal-Mart.  Historically however, she likes to eat out with a high frequency.  She enjoys eating rice as part of her meals.  She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home.  She sleeps two to four hours at a time throughout the day.  She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:,  Today's weight:  155.5 pounds.  Weight from 10/07/04 was 156.7 pounds.  A diet history was obtained.  Blood sugar records for the last three days reveal the following:  fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88.  I instructed the patient on dietary guidelines for gestational diabetes.  The Lily Guide for Meal Planning was provided and reviewed.  Additional information on gestational diabetes was applied.  A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:,  Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day.  Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day.  Her diet history reveals that she has somewhat irregular eating patterns.  In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m.  We discussed the need for small frequent eating.  We identified carbohydrate as the food source that contributes to the blood glucose response.  We identified carbohydrate sources in the food supply, recognizing that they are all good for her.  The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars.  In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice.  We discussed the need for moderating the portion of carbohydrates consumed at one given time.  Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake.  Her weight loss was discouraged.  Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:,  The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan.  The meal plan was devised to distribute her carbohydrates more evenly throughout the day.  The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time.  The meal plan is as follows:  breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings.  Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep.  Encouraged adequate rest.  Also recommend adequate calories to sustain weight gain of one-half to one pound per week.  If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly.  This was a one-hour consultation.  I provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for gestational diabetes.

soap / chart / progress notes, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning

This case involves a pregnant woman with gestational diabetes who is experiencing concerns about her diet's impact on blood sugar levels and is not managing her nutrition effectively due to working night shifts and having a busy lifestyle. The stakes are significant because improper management of gestational diabetes can lead to serious complications for both the mother and the unborn child, including increased risk of macrosomia, preeclampsia, and potential birth injuries. The situation requires careful monitoring, education, and dietary adjustments by medical professionals to ensure the health and safety of both the patient and her baby. However, it doesn't involve immediate life-threatening conditions at this point, as there is still time to adjust and manage the condition properly.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - 4

SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.
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DESCRIPTION: Counting calorie points, exercising pretty regularly, seems to be doing well

soap / chart / progress notes, overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly

The situation involves a patient successfully managing their weight through calorie counting and regular exercise, with support from a dietary consult. The patient is also attending Overeaters Anonymous for additional support, and there is a specific medical interest in learning about diabetic exchanges to prevent hypoglycemia. The stakes for this consult are not immediately critical but do have importance for ongoing patient health and wellness, particularly in managing potential hypoglycemia and diabetes concerns. However, the stakes are not life-threatening or urgent, as per the details provided in the notes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - Diabetes - 2

SUBJECTIVE:,  The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds.  She was diagnosed with type 2 diabetes in 1983.  She is not allergic to any medicines.,DIABETES MEDICATIONS:,  Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper.  Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:,  The patient and her daughter completed both days of diabetes education in a group setting.  Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician.  Fasting blood sugars are 127, 80, and 80.  Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63.  Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109.  Assessment of her knowledge is completed at the end of the counseling session.  She demonstrated increased knowledge in all areas and had no further questions.  She also completed an evaluation of the class.,The patient's feet were examined during the education session.  She had flat feet bilaterally.  Skin color was pink, temperature warm.  Pedal pulses 2+.  Her right second and third toes lay on each other.  Also, the same on her left foot.  However, there was no skin breakdown.  She had large bunions, medial aspect of the ball of both feet.  She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care.  First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels.  Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control.  Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control.  Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:,  Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness.  She is to followup with Dr. XYZ for possible reduction in her insulin doses.
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DESCRIPTION: Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.

soap / chart / progress notes, dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,

This situation is a routine dietary consultation for a patient with type 2 diabetes. There is no immediate danger or critical condition described. The patient's diabetes is well-managed with the current diet changes, and she is making positive efforts towards her health goals. The situation involves regular monitoring and follow-up with a physician for potential medication adjustments, which is typical for diabetes management. While it is important for the patient's ongoing health, it does not constitute a high-stakes or urgent scenario.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dermatitis - SOAP

SUBJECTIVE:,  This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04.  She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema.  I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion.  She comes in today for reevaluation because she is flaring.  Her hands are very dry, they are cracked, she has been washing with soap.  She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin.  She has been wearing some gloves also apparently.  The patient is single.  She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis.  No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker.  No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:,  Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:,  The patient has very dry, cracked hands bilaterally.,IMPRESSION:,  Hand dermatitis.,TREATMENT:,1.  Discussed further treatment with the patient and her interpreter.,2.  Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3.  Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4.  Keflex 500 mg b.i.d. times two weeks with one refill.  Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.
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DESCRIPTION: Hand dermatitis.

Hand dermatitis.

soap / chart / progress notes, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis

The scenario described is a routine follow-up visit for an established dermatological condition, hand dermatitis, which is not immediately life-threatening. While it affects the patient's quality of life, it does not present an urgent or high-risk medical situation at this point. The treatment plan involves common dermatological interventions and is handled on an outpatient basis with follow-up appointments, indicating it's being managed effectively as a chronic condition rather than an acute medical emergency.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Diabetic Foot Care

S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown.  Her toenails are thick and opaque.  Vibratory sensation appears to be intact.  Dorsal pedal pulses are 1/4.  There is no hair growth seen on her toes, feet or lower legs.  Her feet are warm to the touch.  All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1.  Onychocryptosis.,
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DESCRIPTION: An 83-year-old diabetic female presents today stating that she would like diabetic foot care.

soap / chart / progress notes, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic,

This situation involves an elderly diabetic patient with a common complication of diabetes, onychocryptosis (ingrown toenail). While it is a medical situation that requires attention, it is not immediately life-threatening. However, for diabetic patients, foot care is crucial due to the risk of infection and peripheral neuropathy, which can lead to more severe complications if not addressed promptly. Thus, the situation is moderately high-stakes due to the potential for complications if left untreated.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - 1

SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.
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DESCRIPTION: Elevated cholesterol and is on medication to lower it.

soap / chart / progress notes, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol

The situation involves a patient who is making lifestyle changes to address elevated cholesterol levels. While elevated cholesterol can lead to serious health issues like heart disease if not managed properly, the patient is actively working on improving his diet and exercise routine. His efforts and understanding of the necessary changes reduce the immediate high-stakes nature of the situation. The stakes could be higher if the patient were non-compliant or if any immediate medical intervention was necessary. However, since the patient is already showing progress and has a plan in place, the situation is not extremely high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: COPD & Pneumonia - SOAP

SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation.  The patient does have a longstanding history of COPD.  However, she does not use oxygen at her independent assisted living home.  Yesterday, she had made improvement since being here at the hospital.  She needed oxygen.  She was tested for home O2 and qualified for it yesterday also.  Her lungs were very tight.  She did have wheezes bilaterally and rhonchi on the right side mostly.  She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room.  She stated that she needed to urinate.  She awoke, decided not to call for assistance.  She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  She attempted to walk to the rest room on her own.  She sustained a fall.  She stated that she just felt weak.  She bumped her knee and her elbow.  She had femur x-rays, knee x-rays also.  There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  This morning, she denied any headache, back pain or neck pain.  She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS:  The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  She is 95% on 2 L via nasal cannula.,HEART:  Regular rate and rhythm without murmur, gallop or rub.,LUNGS:  Reveal no expiratory wheezing throughout.  She does have some rhonchi on the right mid base.  She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN:  Soft and nontender.  Her bowel sounds x4 are normoactive.,NEUROLOGIC:  She is alert and oriented x3.  Her pupils are equal and reactive.  She has got a good head and facial muscle strength.  Her tongue is midline.  She has got clear speech.  Her extraocular motions are intact.  Her spine is nontender on palpation from neck to lumbar spine.  She has good range of motion with regard to her shoulders, elbows, wrists and fingers.  Her grip strengths are equal bilaterally.  Both elbows are strong from extension to flexion.  Her hip flexors and extenders are also strong and equal bilaterally.  Extension and flexion of the knee bilaterally and ankles also are strong.  Palpation of her right knee reveals no crepitus.  She does have suprapatellar inflammation with some ecchymosis and swelling.  She has got good joint range of motion however.,SKIN:  She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1.  Acute on chronic COPD exacerbation.,2.  Community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.,3.  Generalized weakness and deconditioning secondary to the above.  Also sustained a fall secondary to instability and not using her walker or calling for assistance.  The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1.  I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.
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DESCRIPTION: Acute on chronic COPD exacerbation and community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.

soap / chart / progress notes, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd

This situation involves a 97-year-old female patient with a medical history of COPD and a recent admission for pneumonia. She has experienced a fall, which could potentially exacerbate her condition. Given her age, the presence of multiple health conditions, and the risk of further injury or health deterioration, there are significant considerations for her ongoing care and coordination of services (e.g., home oxygen, physical therapy, and potentially transitioning to assisted living). However, she is displaying some recovery signs and has a plan for monitoring and support, which mitigates some of the urgency.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Craniopharyngioma - Postop

REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.
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DESCRIPTION: Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.

soap / chart / progress notes, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,

The patient is in a postoperative phase for craniopharyngioma, a type of brain tumor. Although he appears to be recovering well and his symptoms have improved significantly, there is still residual disease. This situation is moderately high-stakes as it involves monitoring and potentially further treatment such as radiation, which could impact his health and quality of life. The stakes are not extremely high at the moment because there is no immediate life-threatening situation, but ongoing management and monitoring are crucial.