CS1-Chart 112 CV
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Medicine
Date
Feb 20, 2024
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docx
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Chart Readiness – Template for Practice SOAP Notes
1.
Chart #: 112
2.
Chief Complaint(s): Follow-up, dilated cardiomyopathy and Congestive Heart Failure
3.
History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.)
The patient is a 49-year-old male presenting to appointment on 11/05/2018 for follow-up dilated cardiomyopathy and Congestive Heart Failure. At his most recent visit in August 2018, his heart failure regimen was advanced by discontinuing Losartan and introducing Entresto. His current regimen consists of Entresto, Carvedilol, Spironolactone, Furosemide, and Potassium, in addition to Aspirin. He reports tolerating Entresto well, he believes his blood pressure may be
slightly lower than baseline. He denies checking his blood pressure regularly at home.
Since his last visit, he denies chest pain, shortness of breath, paroxysmal nocturnal dyspnea, and lower extremity edema. He denies any recent episodes of dizziness, syncope, or presyncope.
He attributes 3-pound weight gain to being less ambulatory. He states that he is sedentary during work and eats only once daily. He reports a decrease in physical activity with a low-salt diet, though he admits to eating a breakfast burrito once every 2-3 weeks.
4.
Review of Systems: *
Copy/paste the below ROS into your answer and remove/add as necessary. Please only include pertinent findings.
Constitutional: Negative chills, fever, fatigue
HENT: Negative sore throat, congestion, otalgia
Eyes: Negative blurred vision, eye pain/discharge/redness
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Respiratory: Negative cough, sputum production, dyspnea, wheezing, hemoptysis
CV: Negative chest pain, DOE, orthopnea GI: Negative abd pain, N/V/D, constipation, hematochezia, melena, heartburn
GU: Negative pelvic pain, dysuria, hematuria, frequency, nocturia
MS: Negative back pain, joint pain, myalgia, limited ROM
Integumentary: Negative rash, erythema, pruritus, abrasion, laceration, postoperative site
Neurological: Negative headache, dizziness, paresthesia, speech change
Psychological: Negative anxiety, depression, suicidal/homicidal ideation, insomnia Endocrine: Negative heat/cold intolerance, hair loss, significant weight gain/loss, polyuria, polydipsia
Hematologic/Lymphatic: Negative easy bleeding, ecchymosis, lymphadenopathy
Constitutional: Positive weight gain
Cardiovascular: Negative chest pain, lower extremity edema
Pulmonary: Negative shortness of breath, paroxysmal nocturnal dyspnea
Neurological: Negative dizziness, syncope, presyncope
5.
Past Medical History: (If verbalized during encounter.)
Dilated cardiomyopathy and Congestive Heart Failure.
6.
Past Surgical History: (If verbalized during encounter.)
Heart Catheterization
7.
Social History: (If verbalized during encounter.)
Employed
8.
Family History: (If verbalized during encounter.)
N/A
9.
Diagnostic Data Discussed:
(Lab work, imaging, EKG, etc. Anything discussed during today’s visit.)
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The patient’s most recent heart catheterization revealed an ejection fraction of 30%, but an Echo in June 2018 revealed an ejection fraction of 50-55%,
10. Physical Examination *Copy/paste the below PE into your answer and remove/add as necessary. Please only include pertinent findings.
Constitutional: Well-developed, well-nourished
Head: AT/NC
Neck: Supple, full ROM, no masses, no bruit, no JVD
Eyes: PERRL, EOMI, sclerae anicteric, normal visual fields
ENT: Nose normal, throat clear, no oral lesions, healthy dentition
Cardiovascular: RRR, no murmur or gallop, normal S1 and S2, intact distal pulses
Respiratory: CTAB, normal aeration
Abdomen: Soft, nontender, nondistended, normal bowel sounds, no masses, no organomegaly
Breasts: Bilateral breasts without mass, fullness, or tenderness Back: No tenderness, normal curvature
Extremities: No edema, no muscular or joint tenderness
Lymphatic: No palpable nodes, no adenopathy
Skin: No suspicious lesions identified
Neurological: Speech clear, memory intact, CN II-XII intact, normal coordination, normal gait, 5/5 strength bilaterally, equal sensation bilaterally
Psychiatric: Appropriate, normal judgement
Vitals: Blood Pressure 108/80
CV: 3/6 systolic murmur radiating to neck and carotids bilaterally. 2/6 holosystolic murmur at apex.
Abdomen: Moderately corpulent. Aorta not palpable
11. Assessment & Plan
First list diagnosis, then type out the plan. Include any labs ordered. Example: 1.) Breast cancer
Start Arimidex 1mg QD.
Symptoms reviewed/discussed. Ordered: CBC, CMP, CA 15-3, CEA
Follow up in 3 months. 2.) Hypertension
Continue Metoprolol 25mg BID.
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Encouraged to monitor BP at home three times daily. Bring list of blood pressure readings to next appointment
.
1.
Dilated cardiomyopathy with Congestive Heart Failure
-Continue current medication regimen of Entresto, Carvedilol, Spironolactone, Furosemide, and Potassium in addition with Aspirin.
-Encouraged to continue a low-salt diet. Will repeat Echo in 4 months and follow-up in clinic after.
2.
Moderate obesity
Discussed importance of increasing exercise to 5-6 days per week and portion control for weight loss.
12. Please list all orders that should be pended for this visit: Include all lab, diagnostic imaging, medications and referrals.
Echocardiogram in 4 months.
13. Scribed for Dr. _____ by _____, medical scribe, on _____ at _____. I, Dr. _____, have personally reviewed and agree with the information entered by the scribe. (Rewrite this sentence in the answer space, filling in the blanks.)