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1,300 | Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. | SOAP / Chart / Progress Notes | Urinary Frequency & Urgency - Followup | HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improve... | soap / chart / progress notes, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding |
1,301 | The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse. | SOAP / Chart / Progress Notes | Urinary Retention - Followup | HISTORY OF PRESENT ILLNESS: , The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after... | soap / chart / progress notes, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence, |
1,302 | He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. | SOAP / Chart / Progress Notes | SOAP - Substance Abuse | SUBJECTIVE: , This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. He has a history of doing heroin... | soap / chart / progress notes, addicted to drugs, substance abuse, abuse, heroin, methadone |
1,303 | The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. | SOAP / Chart / Progress Notes | SOAP - Shortness of Breath | SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. I understand she was s... | soap / chart / progress notes, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr, |
1,304 | She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline ... | SOAP / Chart / Progress Notes | SOAP - Cholecystitis | SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with ... | soap / chart / progress notes, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis |
1,305 | Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoa... | SOAP / Chart / Progress Notes | SOAP - Lung Mass | SUBJECTIVE:, The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. The patient is doing fairly well. This afternoon, she called me because heart rate was in the range of 120... | soap / chart / progress notes, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation, |
1,306 | Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected. | SOAP / Chart / Progress Notes | SOAP - Numbness & Tingling | SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of r... | soap / chart / progress notes, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling |
1,307 | MRI demonstrated right contrast-enhancing temporal mass. | SOAP / Chart / Progress Notes | SOAP - Temporal Mass | SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass. Given the characteristics of this mass and his new onset seizures, it is significantly concerning ... | soap / chart / progress notes, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE |
1,308 | Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial. | SOAP / Chart / Progress Notes | Sleep Study Followup | REASON FOR VISIT:, This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time, she was evaluated and found to ... | null |
1,309 | The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. | SOAP / Chart / Progress Notes | Shortness Of Breath - Progress Note | She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has b... | soap / chart / progress notes, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE |
1,310 | Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. | SOAP / Chart / Progress Notes | Sleep Apnea | REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to ... | soap / chart / progress notes, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep, |
1,311 | Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression. | SOAP / Chart / Progress Notes | Refractory Hypertension - Followup | PROBLEM LIST:,1. Refractory hypertension, much improved.,2. History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3. History of GI bleed in 1995.,4. History of depression.,HISTORY OF PRESENT ILLNESS:, This is a return visit to the renal clinic for this patient. She is an 85-year-old woman ... | soap / chart / progress notes, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia |
1,312 | A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis. | SOAP / Chart / Progress Notes | Sexual Dysfunction - Chart Note | SUBJECTIVE:, The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction. Patient reports that he would like to try Cialis to see if it will improve his erectile performance. Patient states that he did a quiz on-line at the Cialis web site and did not score in the no... | soap / chart / progress notes, cialis, able to maintain, erectile, sexual activity, sexual dysfunction, blood pressure, maintain, dysfunction, erections, sexual |
1,313 | Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine. | SOAP / Chart / Progress Notes | Rheumatology Progress Note | SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. S... | soap / chart / progress notes, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected, |
1,314 | Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. | SOAP / Chart / Progress Notes | Pulmonary Medicine Clinic Followup | SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and w... | soap / chart / progress notes, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary, |
1,315 | Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis. | SOAP / Chart / Progress Notes | Rotator Cuff Tear | REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y... | soap / chart / progress notes, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical, |
1,316 | A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall. | SOAP / Chart / Progress Notes | Recheck of ADHD Meds | SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like... | soap / chart / progress notes, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall, |
1,317 | Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. | SOAP / Chart / Progress Notes | Pulmonary - Followup Note | SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficul... | soap / chart / progress notes, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary, |
1,318 | A 16-year-old male with Q-fever endocarditis. | SOAP / Chart / Progress Notes | Q-Fever Endocarditis | HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports tha... | soap / chart / progress notes, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever, |
1,319 | Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 3 | PHYSICAL EXAMINATION: , The patient is a 63-year-old executive who was seen by his physician for a company physical. He stated that he was in excellent health and led an active life. His physical examination was normal for a man of his age. Chest x-ray and chemical screening blood work were within normal limits. Hi... | soap / chart / progress notes, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma |
1,320 | Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 2 | PHYSICAL EXAMINATION:, This 71-year-old man went to his primary care physician for a routine physical. His only complaints were nocturia times two and a gradual "slowing down" feeling. The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate g... | soap / chart / progress notes, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma |
1,321 | A 65-year-old man with chronic prostatitis returns for recheck. | SOAP / Chart / Progress Notes | Prostatitis - Recheck | SUBJECTIVE:, The patient is a 65-year-old man with chronic prostatitis who returns for recheck. He follow with Dr. XYZ about every three to four months. His last appointment was in May 2004. Has had decreased libido since he has been on Proscar. He had tried Viagra with some improvement. He has not had any urinar... | null |
1,322 | Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 4 | PHYSICAL EXAMINATION:, Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0. All other systems were normal.,PROCEDURES: ,Sextant biopsy of the prostate.,Radical prostatectomy: Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small ... | soap / chart / progress notes, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate, |
1,323 | Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate. | SOAP / Chart / Progress Notes | Prostate Adenocarcinoma - 1 | HISTORY:, This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction. After catheterization, the patient underwent cystoscopy on 4/13. On 4/14 the patient underwent a transurethral resection of the p... | soap / chart / progress notes, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma, |
1,324 | The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA. | SOAP / Chart / Progress Notes | Prostate Fossa Irradiation - Followup | HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. His urinary function had been stable until 2 days ago. Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated a... | null |
1,325 | Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis. | SOAP / Chart / Progress Notes | Progress Note - Supraglottitis | HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. Please refer to chart for history and physical an... | soap / chart / progress notes, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis |
1,326 | Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. | SOAP / Chart / Progress Notes | Progress Note - Liver Cirrhosis | HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. The patient at that time stated that he had established diagnosis of liver cirrhosis. Since the las... | soap / chart / progress notes, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis, |
1,327 | Patient developed iron deficiency anemia and had blood in his stool. | SOAP / Chart / Progress Notes | Progress Note - Iron Deficiency Anemia | HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool. The patient also has chronic diarrhea. His anemia was diagnosed months ago when he presented with unusual pruritus and h... | null |
1,328 | Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. | SOAP / Chart / Progress Notes | Polycythemia Rubra Vera | CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levoth... | soap / chart / progress notes, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia, |
1,329 | This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. | SOAP / Chart / Progress Notes | Postop Parathyroid Exploration & Parathyroidectomy | SUMMARY: ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. She put out 1175 mL of urine since surgery. Her incision looks good. IV site and extremities are unrema... | soap / chart / progress notes, parathyroid hyperplasia, parathyroid exploration, pth, hyperplasia, parathyroidectomy, parathyroidNOTE |
1,330 | 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 | 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... | 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, |
1,331 | Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. | SOAP / Chart / Progress Notes | Podiatry - Progress Note | SUBJECTIVE:, Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is curren... | soap / chart / progress notes, progress note, plantar fascitis, podiatry, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel |
1,332 | Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy. | SOAP / Chart / Progress Notes | Posttransplant Lymphoproliferative Disorder | CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1. Posttransplant lymphoproliferative disorder.,2. Chronic renal insufficiency.,3. Squamous cell carcinoma of the skin.,4. Anemia secondary to chronic renal insufficiency and chemotherapy.,5. Hypertension.,HISTORY OF PRESENT ILL... | soap / chart / progress notes, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative, |
1,333 | A 44-year-old, 250-pound male presents with extreme pain in his left heel. | SOAP / Chart / Progress Notes | Plantar Fasciitis | S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He als... | soap / chart / progress notes, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar, |
1,334 | Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. | SOAP / Chart / Progress Notes | Physical Therapy - Outpatient Rehab | SUMMARY: ,The patient has attended physical therapy from 11/16/06 to 11/21/06. The patient has 3 call and cancels and 3 no shows. The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE: ,The patient states pain still significant, primarily 1s... | null |
1,335 | Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her. | SOAP / Chart / Progress Notes | PAF - 6-Month Followup | REASON FOR VISIT:, Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid... | soap / chart / progress notes, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial, |
1,336 | Pain management sample progress note. | SOAP / Chart / Progress Notes | Pain Management Progress Note | DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox inj... | soap / chart / progress notes, progress note, management, muscle |
1,337 | Overactive bladder with microscopic hematuria. | SOAP / Chart / Progress Notes | Overactive Bladder | REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during... | soap / chart / progress notes, overactive bladder with microscopic hematuria, irritative voiding symptoms, anticholinergic, microscopic hematuria, overactive bladder, ditropan, microscopic, hematuria, bladder, overactive |
1,338 | The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day. | SOAP / Chart / Progress Notes | ORIF Facial Fractures - Followup | Mr. ABC was transferred to room 123 this afternoon. We discussed this with the nurses, and it was of course cleared by Dr. X. The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital ... | soap / chart / progress notes, fenestrated tube, nasal fracture, facial fractures, orif, tracheotomy, tube, fractures, |
1,339 | A 47-year-old white female presents with concern about possible spider bite to the left side of her neck. | SOAP / Chart / Progress Notes | Possible Spider Bite | SUBJECTIVE:, This 47-year-old white female presents with concern about possible spider bite to the left side of her neck. She is not aware of any specific injury. She noticed a little tenderness and redness on her left posterior shoulder about two days ago. It seems to be getting a little bit larger in size, and sh... | soap / chart / progress notes, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite, |
1,340 | Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak. | SOAP / Chart / Progress Notes | Poison Ivy - SOAP | SUBJECTIVE:, He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackma... | soap / chart / progress notes, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison |
1,341 | Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture. | SOAP / Chart / Progress Notes | ORIF - Followup | REASON FOR VISIT:, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction interna... | soap / chart / progress notes, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif, |
1,342 | Ophthalmology followup visit note. | SOAP / Chart / Progress Notes | Ophthalmology Progress Note - 2 | A fluorescein angiogram was ordered at today's visit to rule out macular edema. We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress. A copy of the angiogram is enclosed for your records. | soap / chart / progress notes, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, ophthalmology, len... |
1,343 | Orthopedic progress note for follow up of osteoarthritis, knees. | SOAP / Chart / Progress Notes | Osteoarthritis - Progress Note | CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain: Localized to the bi... | null |
1,344 | Ophthalmology followup visit note. | SOAP / Chart / Progress Notes | 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. | 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 e... |
1,345 | MGUS. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS. | SOAP / Chart / Progress Notes | MGUS Followup | CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:, This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.... | null |
1,346 | Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis. | SOAP / Chart / Progress Notes | 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 follo... | soap / chart / progress notes, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications, |
1,347 | A woman with end-stage peritoneal mesothelioma with multiple bowel perforations. | SOAP / Chart / Progress Notes | Mesothelioma - Chart Note | The patient's home regimen includes Duragesic patch at 125 mcg every 3 days. She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum. The patient was offered multiple procedures to help with her abdominal pain including a thoraci... | soap / chart / progress notes, pleurodesis, abdominal pain, multiple bowel perforations, peritoneal mesothelioma, mesothelioma, peritonealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and qu... |
1,348 | Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator. | SOAP / Chart / Progress Notes | Multiple Progress Notes | PROGRESS NOTES,4/16/01:,Patient in respiratory failure, on ventilator,Request airline placement,Airline tracing good,4/17/01:,S: Sedated, intubated in NAD,O: Lungs: Increased bibasilar crackles,A/P: Respiratory arrest, pneumonia, COPD exacerbation,Replete K+, continue IVABX, start TPN, decrease TV, review ABGs,4/18/01:... | null |
1,349 | Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.) | SOAP / Chart / Progress Notes | Multiple Medical Problems | SUBJECTIVE:, The patient was seen today by me at Nursing Home for her multiple medical problems. The nurses report that she has been confused at times, having incontinent stool in the sink one time but generally she does not do that poorly. She does have trouble walking which she attributes to weak legs. She fell a... | soap / chart / progress notes, progress note, alzheimer’s dementia, b12 deficiency, fatigue, hypertension, osteoporosis, digoxin, incontinent stool, multiple medical problems, weak, weight loss, multiple, dementia, alzheimer’s, incontinent, |
1,350 | 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 | 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. ... | 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, |
1,351 | A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant. | SOAP / Chart / Progress Notes | Mantle Cell Lymphoma | PRINCIPAL DIAGNOSES:,1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3. ... | null |
1,352 | Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive ... | SOAP / Chart / Progress Notes | Melena - ICU Followup | HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic ob... | soap / chart / progress notes, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding |
1,353 | Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. | SOAP / Chart / Progress Notes | Non-Hodgkin lymphoma Followup | CHIEF COMPLAINT:, Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin... | null |
1,354 | Neurologic examination sample. | SOAP / Chart / Progress Notes | Neurologic Examination | NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of ny... | soap / chart / progress notes, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE |
1,355 | Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax. | SOAP / Chart / Progress Notes | Lung Cancer Followup | CHIEF COMPLAINT:,1. Extensive stage small cell lung cancer.,2. Chemotherapy with carboplatin and etoposide.,3. Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment wit... | soap / chart / progress notes, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer, |
1,356 | Patient is here to discuss possible open lung biopsy. | SOAP / Chart / Progress Notes | 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 h... | 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 provide... |
1,357 | A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle. | SOAP / Chart / Progress Notes | Leg Pain & Bone Pain | CHIEF COMPLAINT:, Leg pain.,HISTORY OF PRESENT ILLNESS:, This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occas... | soap / chart / progress notes, cmp, hypercholesterolemia, leg pain, type ii diabetes, ankle, blood sugars, bone pain, buttocks, pain, radiates from her buttocks, leg pain/bone, leg, sugars, weight, |
1,358 | History of right leg pain. Leg pain is no longer present. | SOAP / Chart / Progress Notes | Leg Pain - Progress Note | HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, ... | null |
1,359 | Patient status post lap band placement. | SOAP / Chart / Progress Notes | 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 ... | soap / chart / progress notes, lap band adjustment, lap band placement, lap band, |
1,360 | Patient with a history of ischemic cardiac disease and hypercholesterolemia. | SOAP / Chart / Progress Notes | Ischemic Cardiac Disease - Progress Note | HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old man who returns for recheck. He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test. He did walk for 8 minutes. The scan showed some mild inferior wall scar and ejection fraction was well preserved... | null |
1,361 | The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago. | SOAP / Chart / Progress Notes | Lobectomy - Followup | HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwen... | soap / chart / progress notes, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer |
1,362 | Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation. | SOAP / Chart / Progress Notes | 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.,Preoperat... | 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, |
1,363 | This patient has reoccurring ingrown infected toenails. | SOAP / Chart / Progress Notes | Infected Toenails | S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing ... | soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected, |
1,364 | Patient with hypertension, syncope, and spinal stenosis - for recheck. | SOAP / Chart / Progress Notes | 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: ,Ateno... | soap / chart / progress notes, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea, |
1,365 | Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds. | SOAP / Chart / Progress Notes | HIV Followup - 1 | PROBLEM LIST:,1. HIV stable.,2. Hepatitis C chronic.,3. History of depression, stable off meds.,4. Hypertension, moderately controlled.,CHIEF COMPLAINT: , The patient comes for a routine followup appointment.,HISTORY OF PRESENTING ILLNESS: , This is a 34-year-old African American female who comes today for routine ... | null |
1,366 | Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse. | SOAP / Chart / Progress Notes | 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. ... | 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, |
1,367 | One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well. | SOAP / Chart / Progress Notes | Gen Med SOAP - 7 | CHIEF COMPLAINT:, One-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I thin... | null |
1,368 | Patient today with multiple issues. | SOAP / Chart / Progress Notes | Gen Med SOAP - 8 | SUBJECTIVE: , I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and stroke. This is the second time he has had ... | soap / chart / progress notes, multiple issues, atrial fibrillation, gross hematuria, multiple, bph, fibrillation, hematuria, |
1,369 | Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology. | SOAP / Chart / Progress Notes | HIV Followup | HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease. His last CD4 count was 425, viral load was less than 50 in 08/07. He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus. He also has a history ... | soap / chart / progress notes, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension, |
1,370 | Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain | SOAP / Chart / Progress Notes | Gen Med SOAP - 6 | SUBJECTIVE:, The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eatin... | soap / chart / progress notes, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck, |
1,371 | Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change. | SOAP / Chart / Progress Notes | Hand Discomfort - Followup | REASON FOR RETURN VISIT: , Followup of left hand discomfort and systemic lupus erythematosus.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater ... | null |
1,372 | The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure. | SOAP / Chart / Progress Notes | Gen Med SOAP - 11 | SUBJECTIVE:, The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to hav... | soap / chart / progress notes, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure, |
1,373 | The patient has NG tube in place for decompression. | SOAP / Chart / Progress Notes | 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... | soap / chart / progress notes, small bowel obstruction, paralytic ileus, decompression, ng tube, pedal swelling, prophylaxis |
1,374 | Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc. | SOAP / Chart / Progress Notes | Gen Med SOAP - 2 | SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110... | soap / chart / progress notes, general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery |
1,375 | Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 8 | SUBJECTIVE:, The patient is an 89-year-old lady. She actually turns 90 later this month, seen today for a short-term followup. Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. Blood pressure is better even though she is no... | soap / chart / progress notes, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose, |
1,376 | General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, | SOAP / Chart / Progress Notes | 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 a... | 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 |
1,377 | General Medicine SOAP note. | SOAP / Chart / Progress Notes | 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 s... | 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, |
1,378 | Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea. | SOAP / Chart / Progress Notes | 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 someth... | soap / chart / progress notes, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety, |
1,379 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | Gen Med SOAP - 1 | SUBJECTIVE:, | soap / chart / progress notes, progress note, clear to auscultation, s1, s2, s3, s4, blood pressure, clubbing, cyanosis, general medicine, peripheral edema, rubs, tenderness, abdomen, pressure, soap, blood |
1,380 | General Medicine SOAP note. | SOAP / Chart / Progress Notes | Gen Med SOAP - 4 | S:, ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that... | soap / chart / progress notes, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, general medicine, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial, |
1,381 | Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 9 | SUBJECTIVE:, The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in the morning when she is up, but then t... | soap / chart / progress notes, leg swelling, leukocytosis, joint pain, left shoulder, low back pain, obesity, frequency with urination, tobacco abuse, multiple problems, blood count, blood pressure, leg, shoulder, tobacco, swelling, weight |
1,382 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 2 | CHIEF COMPLAINT:, Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:, This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and... | soap / chart / progress notes, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, general medicine, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress, |
1,383 | A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 6 | SUBJECTIVE:, This 3-year-old male is brought by his mother with concerns about his eating. He has become a very particular eater, and not eating very much in general. However, her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots, within 5 to 10 ... | soap / chart / progress notes, eating, foods, vomiting, reactive airway disease, raw carrots, carrots, |
1,384 | Patient with a three-day history of emesis and a four-day history of diarrhea | SOAP / Chart / Progress Notes | Gen Med Progress Note - 7 | SUBJECTIVE:, The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because th... | soap / chart / progress notes, diarrhea, emesis, history of, gastroenteritis, viral, brat diet, progress note, |
1,385 | A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 5 | SUBJECTIVE:, The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. She follows with Dr. XYZ on her hypertension, as well as myself. She continues to gain weight. Diabetes is therefore a major concern. In fact, her dad had diabetes and she has... | null |
1,386 | The patient is in complaining of headaches and dizzy spells. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 4 | SUBJECTIVE:, The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias. She has... | soap / chart / progress notes, headaches and dizzy spells, chest pains, shoulder, progress, headaches, |
1,387 | Sepsis due to urinary tract infection. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 13 | SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS: Temperature is 95.4. Highest temperature recorded over the past 24 hours is 102.1.,CHEST: Examination of the chest is clear to auscultation.,CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.,ABDOME... | soap / chart / progress notes, sepsis, escherichia coli, urinary tract infection, doripenem, troponin, urinary, infection |
1,388 | Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 12 | SUBJECTIVE: , The patient was seen and examined. He feels much better today, improved weakness and decreased muscular pain. No other complaints.,PHYSICAL EXAMINATION:,GENERAL: Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS: Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.... | soap / chart / progress notes, rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity, cardiac enzyme, blood pressure, |
1,389 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | 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 da... | null |
1,390 | Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 10 | CHIEF COMPLAINT:, The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if sh... | null |
1,391 | Sample progress note - Gen Med. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 1 | CHIEF COMPLAINT:, Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:, This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see ... | soap / chart / progress notes, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin, |
1,392 | Patient having foot pain. | SOAP / Chart / Progress Notes | 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... | soap / chart / progress notes, soap, foot pain, primary care physician, project access, insurance, foot, project, access, care, appointment |
1,393 | The patient states that he feels sick and weak. | SOAP / Chart / Progress Notes | Gen Med Progress Note | SUBJECTIVE:, The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS: Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL: The patient looks tired.,HEENT: Oral mucosa is dry.,CHEST: Clear to auscultation. He states that he has a mild co... | soap / chart / progress notes, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature, |
1,394 | Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access. | SOAP / Chart / Progress Notes | Fundoplication & Gastrostomy Followup | REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feedin... | soap / chart / progress notes, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication, |
1,395 | Follow up consultation, second opinion, foreskin. | SOAP / Chart / Progress Notes | Foreskin - Followup | REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well. He has a relatively unremarkable foreskin. At this point in time, he otherwise seems to be doing reasonably well. The question is about the foreskin. He o... | soap / chart / progress notes, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin, |
1,396 | 5-month recheck on type II diabetes mellitus, as well as hypertension. | SOAP / Chart / Progress Notes | Gen Med Progress Note - 11 | SUBJECTIVE:, The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain r... | |
1,397 | Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma. | SOAP / Chart / Progress Notes | Evaluation of Allergies | HISTORY:, A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physi... | soap / chart / progress notes, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy |
1,398 | Fifth disease with sinusitis | SOAP / Chart / Progress Notes | Fifth Disease - SOAP | SUBJECTIVE:, Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school... | soap / chart / progress notes, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx, |
1,399 | Preop evaluation regarding gastric bypass surgery. | SOAP / Chart / Progress Notes | 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. Tempe... | soap / chart / progress notes, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass, |
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