PROBLEM: Left middle trigger digit, right middle and ring trigger digits, and right carpal tunnel. SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #3
Call if any new symptoms develop or current symptoms worsen. We discussed what Dexilant is, how it works, and potential side effects.ģ.
Non-insulin-dependent diabetes mellitus.ġ. Abdominal pain, most consistent with acid peptic symptoms, no red flags.ģ. He belches every time on palpation of the left upper quadrant. Abdomen: Normal bowel sounds, soft with possible left upper quadrant tenderness, but he says no. Lungs are clear to auscultation and percussion. Neck is supple without thyromegaly or adenopathy. HEENT: Reveals no sinus tenderness and posterior pharynx is clear. Blood pressure 122/74, pulse 82 and regular, respiratory rate 18 and unlabored, weight 290 pounds, oxygen saturation is 98%. OBJECTIVE: He is alert and oriented and in no distress at rest. No orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. He has not been testing his sugars, and there has been no dyspnea or chest discomfort with exertion. No dysphagia, melena, change in bowel habits, or vomiting. He also has increased satiety, heartburn, and intermittent left upper quadrant pain. It has been building up for about three months, and his most prominent symptom is increased belching. SUBJECTIVE: The patient was seen on an emergency basis today when he called complaining of left upper quadrant pain. SOAP Note or Chart Note or Progress Note Medical Transcription Sample Report #2 Once we receive culture results, we will call the patient if any antibiotics need to be added or changed.ħ. We will send a prescription to have a specially molded CROW boot made to help offload the forefoot and help allow for wound healing.Ħ. Discussed with patient about using a special boot to help offload the forefoot when she does walk.ĥ. The patient understands and will try to keep her wound covered.Ĥ. The patient understands that if she continues to come into the clinic without a dressing on her infected foot, she may be barred from returning to the wound care center.
The patient does have a history of MRSA and it is not acceptable for her to be coming to the clinic without a dressing for her foot wound. Tried to explain to her that not having a dressing is a health risk to other patients as well as to her. Discussed with patient about not wearing a dressing. The patient is to continue doing daily dressing changes with silver alginate.ģ. The wound on left foot is sharply debrided.Ģ. Status post right below-knee amputation.ġ. The patient is also being sent for hemoglobin A1c to assess her diabetes.Ĥ. Left plantar foot wound is cultured today. The patient is status post left first ray amputation and right BKA.
No bone visible in the wound at this time. There is no streaking or purulent drainage. The foot appears to be much more swollen than last visit. The wound bed is fibrotic with some bleeding with debridement. She also has a malodor coming from the foot wound. There is a significant amount of periwound callus with maceration. OBJECTIVE: The patient has a large wound on the plantar aspect of her left forefoot area. She has been taking her antibiotics and denies any constitutional symptoms at this time. She recently took a medical leave from work for the next three months to try and stay off her feet. The patient states that she was too tired to put her dressing on. The patient comes in without any dressing on her foot for approximately the fourth time in the last few weeks. SUBJECTIVE: This (XX)-year-old woman returns to the wound care center for followup of left plantar foot wound.
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