Sample Name: Gen Med SOAP - 8
Description: Patient today with multiple issues.
(Medical Transcription Sample Report)
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 significant gross hematuria this month. He also fell about a week ago and is complaining of buttock pain and leg pain. We did get x-rays of hips, knees, and ankles. Clearly, he has significant degenerative disease in all these areas. No fractures noted however. He felt that the pain is pretty severe and particularly worse in the morning. His sinuses are bothering him. He wonders about getting some nasal saline spray. We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.
PHYSICAL EXAMINATION: Vitals: As in chart. The patient is alert, pleasant, and cooperative. He is not in any apparent distress. He is comfortable in a seated position. I did not examine him further today.
ASSESSMENT AND PLAN:
1. Hematuria. Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH. We will also obtain a repeat UA as he did describe to me some dysuria. However, I do not think this would account for the gross hematuria. He will be started on an aspirin 81 mg p.o. daily.
2. For the pain we will try him on Lortab. He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.
3. We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.
4. For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use.
Keywords: general medicine, multiple issues, atrial fibrillation, gross hematuria, multiple, bph, fibrillation, hematuria,