SFFC Sample Progress Note

Key points: This example uses problem-based charting, we use one liners at the top of HPI and A/P, don’t forget to sign your notes!  

In this example the italics are to provide context and don’t need to go in an actual note.  

 

Header: New/Established Patient Office Visit  

Age/Sex CC: 50 y/o F here for HTN, DM2 follow up and new L wrist pain, 

Problem based HPI: 

#DM2: Pt reports compliance with current regimen of metformin 1000 mg BID and dulaglutide 1.5mg weekly.  

  • she checks fasting FBG several times and week and bring log today: 100-140. Last A1c 6.8 (date). 

  • she denies side effects from medications, no hypoglycemia, no nausea no GI disturbance   

  • she reports 2 lbs wt. loss since last visit with diet changes  

 

#HTN: Pt reports compliance with current regimen of lisinopril 20mg daily   

  • she checks blood pressure once per week and brings log today: SBP 118-130/65-80 

  • she denies side effects from medications; no CP, SOB, no LEE (lower extremity edema)   

  • she reports working on DASH diet after meeting with Jason 1 month ago  

 

#L wrist pain: 3 wks intermittent gradually worsening pain, worse when working in restaurant  

  • pain is sharp, moderate severity and interferes with work  

  • no swelling or radiation, no h/o trauma, no other joint pain  

  • has not tried anything to treat the pain 

Meds:  
Metformin 1000mg BID
Dulagutide 1.5 mg weekly  
Lisinopril 20 mg daily  
Vit D3 800 IU daily  

PMH: 
DM2 – dx’d 2014, well controlled 
HTN – dx’d 2020, well controlled 

SHx – ACL reconstruction 2005 at Kaiser  

FHx – Mother - DM2 and HTN, Father - Prostate CA, PGM – Breast CA, MGF – Lung CA 

Social – Lives with wife and 4-year-old daughter, works as chef, EtOH 5 drinks/wk, No h/o smoking tobacco, drugs – occasional MJ 1/mo. Monogamous relationship.  

PE:  
VS: 125/77, HR 65 BMI 29 
Gen: NAD 
HEENT: PERRL, OP clear, no LAD 
CV: rrr no m/r/g  
Lungs: CTAB 
Abd: soft nonTTP (tender to palpation) nondistended 
MSK: 
Left wrist - No e/o swelling, None TTP over bony landmarks, no snuffbox tenderness, FROM with flexion, extension, supination, and pronation. Strength 5/5. No thenar atrophy. + Phalen’s and Tinel’s tests.  
LE: 1+ nonpitting edema  

A/P: 

One-liner: 50 y/o F with well controlled DM2 and HTN here for lab follow up and 3 wks worsening L wrist pain.  

 Problem based charting:  

 #L Wrist Pain – likely MSK pain, no e/o inflammatory or infectious process. No h/o trauma and + Phalen’s and Tinel’s tests makes carpel tunnel likely etiology.  

  • Pt given a neutral wrist splint, recommend using ATC until f/u visit  

  • Trial with ibuprofen 600 mg TID with food x 1 wk, consider tums if dyspepsia  

  • Use ice PRN BTP (break through pain)  

  • f/u 1 week 

 #DM2 – well controlled on current regimen of metformin 1000 mg BID and Dulagutide 1.5 mg weekly. Last A1c 6.8 (date). 

  • could consider stopping home FSBG (finger stick blood glucose) but pt preferred to check intermittently 

  • Continue diet changes, congrats on 2 lbs wt loss!  

  • Check urine alb:cr today, Normal in last year 

  • Referred to eye clinic for retinal screen today  

  • Due for a1c, lipids and CMP in 6 mo.  

  • Monofilament due in 6 months 

  • PNV23 2020  

 

SFFC DM TEMPLATE (this is the only part of the chart that can be ‘copied forward’): 

Type II date dx: 11/3/2020 @ SFFC 

A1C trend: 01/29/2022 7.2%, 6/21 POC 7.8%, 1/3/19 8.1% 

Devices/monitoring: none 

Medication reconciliation at today’s visit: 
Metformin 1000mg BID (did not need refills) 
Atorvastatin 40mg QD 
Dulagutide 1.5 mg 

  

DM HCM 
- foot check: 11/22 intact, no sensation deficits 

- eye check- visited Lions Eye clinic 7/22 for macular degeneration f/u and diabetic retinopathy check 

- Lipids/ASCVD: 9/22 lipids  LDL 109, ASVD 15% 

- Vit B12: 209 3/22 

- microalbumin normal 3/22  

  

Vaccinations: 

- Pneumovax: 8/2020 
- TDAP: 6/2018 
- Flu: 09/2022 
- COVID: #1 7/21, #2 9/21, Boosters 2/22, 6/22, 10/22 
- Hep B: 1/2019, 5/2019, 12/20 
- Shingles:  6/2022, 8/2022 

#HTN – Goal is <130/80 (ACC/AHA). She is well controlled on current regimen of lisinopril 20mg 

  • Continue weekly HBP testing  

  • Continue dash diet, great job! 

  • Check urine alb:cr today 

  • CMP in 6 mo for Cr  

 

#Insurance – She recently moved to SF and likely qualifies for Healthy San Francisco. HSF pamphlet and website info were provided. She declined MSW appointment but plans to looking to signing up.   

 

#HCM (if using DM Template do not need to duplicate information here)  –  

  • Annual FIT due in 6 months  

  • Tdap UTD (2018) 

  • Flu today 

  • COVID x 4, booster (9/2022) 

  • Mammogram due in 6 months 

  • Pap normal 2019, HPV negative, next 2024 

  • Hep A/B immune  

  • HCV screen neg (10/2021) 

  • HIV screen neg (10/2021) 

Signed: Johnathan Appleseed MS3 
Seen with attending Dr. Nelligan