Note Report Samples (4)

Medical note report samples:



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Note Report Sample #1

RE: David Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

SUBJECTIVE: This is a 32-year-old gentleman who came in for reevaluation of diabetes mellitus. He was started on Metformin 500 mg t.i.d last week and so far he has tolerated the medication well. He stated he is feeling a lot better. He has no more polyuria, no polydipsia, and he has more energy.

LABORATORY REVIEW: He had laboratory workup done. It showed glucose of 241, BUN and creatinine is in good range, total bilirubin is 1.2, AST is 49, ALT 135, total cholesterol is 216, triglyceride 180, and hemoglobin A1c is 11.4. He does not have any microalbuminuria.

PHYSICAL EXAMINATION: Blood pressure is 130/70. Respiratory is 16. Pulse is 68. Weight is 242 pounds. Temperature is 98.1 degrees. He is alert and oriented x 3.

ABDOMEN: Flat, soft, and nontender. He has no organomegaly or no jaundice noted.

ASSESSMENT AND PLAN:
1. Diabetes mellitus. I encourage diet and exercise. I also counseled him about decreasing his carbohydrate intake.
2. I will check for hepatitis B and C profile and do an abdominal ultrasound.
3. Patient is to return after his blood test is completed.

Note Report Sample #2

S: She has a pulse of 84. Blood pressure is 120/80. She is here for an acute visit today complaining about a recurrent rash on her right buttock. A few days ago Heidi felt a tingling sensation in her upper right buttock and today noticed that she had developed some small vesicles. It is in a well-circumscribed area, in an area where she had lesions previously. She had cultures done back in May, on May 10th. It occurred first in January of this year. She had light growth of coagulase-negative staphylococcus and that was all on her last bacterial culture. She has had multiple sex partners in her life. She has, she believes, been tested for herpes in the past and was negative. She has been monogamous with her current partner for quite some time now. She is trying to conceive a child and has been sexually active lately and is worried about giving this to her husband.

ROS: Is listed in HPI. Allergies are penicillin and IVP dye. Medications are reviewed. Please see medication sheet.

PMH: Is reviewed. Please see note.

SHX: Is reviewed. Please see note.

PE: She has a 2-3 cm well-circumscribed hyperemic area with small clear vesicles. Bacterial culture is taken. A viral culture is taken. She has no lymph nodes either in her anterior cervical chain, supra or subclavicular or inguinal area.

A&P: Likely herpetic rash. Cultures have been taken. We will also do a check for HSV-1 and HSV-2. I have given her Valtrex 500 mg twice daily for the next three days with p.r.n. refills. We will await the culture results to go further and, in the meantime, we talked about its spread and how to protect her partner. She was agreeable with the above- instructed plan. Risks, benefits and side effects of medications and treatments were discussed, and she will follow up as suggested.

Note Report Sample #3

S: She is here for a re-check of weight. She is being seen on a chronic basis for her failure to thrive. Her normal weight is around 112. She is down to 95. Her pulse is 80. Blood pressure is 110/68. She has met a new friend and is enjoying his company. He is also helping out with things around the house and she appreciates that very much. She has gone to the graduation of her daughter from high school and her son from middle school. Their father came to the son’s ceremony but not his daughter’s, which was her graduation from high school. This had a huge impact on the family. Her son has actually bitten Daniel again and fortunately did not draw blood this time, but they are definitely having difficulties. She is trying to eat more but finding it difficult. Her back is really bothering her. She has had physical therapy but really has not noted any real improvement thus far. She was suggested to try Pilates, which she is doing daily. The pain is worse after working for several days and, although she had the injury on the left, it radiates all the way through to the right. At the end of the week, she has difficulty even walking around in the mall. She takes Naprosyn and Prilosec for her pain. She notes a slight improvement. She has no bowel or bladder symptoms but the pain radiates into her posterior thigh and makes her knee joint feel unstable.
ROS: Is listed in the HPI or otherwise negative. She has no known drug allergies. Medications are reviewed. See medication sheet.
PMH: Is reviewed. No changes.
SHX: Social history is reviewed. No changes, except as listed in the HPI.
PE: This is a well-appearing thin middle-aged female. She has slight exophthalmus, anicteric and pupils are equal round and reactive to light. She is very thin appearing with very little musculature. Her veins are clearly visible. She has no thyromegaly. Chest is clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm. Her abdomen is scaphoid but soft with audible bowel sounds, is nontender and without organomegaly. Her extremities are warm and well perfused. There is no edema.
A&P: 1. Reactionary depression. She is on Lexapro, taking Xanax only as needed. This seems to be improving her mood.2. Anxiety. Please see #1.3. Low back pain, herniated disc at L4-L5. She continues to see physical therapy. Unfortunately, though, she is not getting a lot of improvement.

4. Varicose veins. She is trying support pantyhose. At the end of the day, especially when she has worked for a couple days in a row, she has deep, aching pain in her legs.

5. Hemorrhoids. No symptoms.

6. Irregular menses. She has perimenopausal.

7. Failure to thrive, weight loss. She was encouraged to eat three meals and three snacks a day to include dense foods, such as ice cream and nuts. She expressed understanding.

8. Osteopenia. She continues to take her vitamin D for her vitamin deficiency. She is also taking Actonel. She has no esophageal problems, but she does need lab work done in August. She was agreeable with the above-instructed plan. Risks, benefits and side effects of medication and treatments were discussed, and she will follow up as suggested.

Note Report Sample #4

RE: Debra Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

The patient presents complaining of bilateral knee pain. She is known to have degenerative disc disease with osteoarthritis of the knees.

On examination, both knees are tender, minimally swollen and warm. Straight leg raising test is negative. The sensory examination of the back is unremarkable and the back is nontender.

Under ultrasound guidance I did first the right and then the left knee injections, each with 20 mg of Kenalog and a cc of lidocaine. A total of 40 mg of Kenalog were used and two ultrasonographic images were recorded of each procedure.

DIAGNOSIS: Osteoarthritis of the knees, synovitis, and degenerative disc disease of the back. Routine visit.



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