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Mary
Visit - 10/27/2025
10/27/2025, 1:33 PM

Mary, 52F

Primary Care
Family Medicine
Internal Medicine
More

Visit - 10/27/2025

Subjective:

52-year-old female, new patient establishing care. Chief complaint: 6 months of fatigue and occasional palpitations. Medical history: hypothyroidism (on levothyroxine 100mcg), hypertension (on lisinopril 10mg).

Objective:

BP 128/82, pulse 76 regular, BMI 28.5. Cardiovascular and lung exams normal. Thyroid non-enlarged, no nodules.

Assessment and Plan:

  • Fatigue and palpitations: Order TSH, CBC, metabolic panel, ECG to rule out thyroid issues, anemia, or arrhythmia
  • Hypothyroidism: Check levels and adjust medication if needed
  • Hypertension: Continue current medication, recheck in 3 months

Patient Education:

  • Explained workup for fatigue symptoms
  • Discussed stress management and cardiovascular risk reduction
  • Reviewed medication adherence

Follow-up scheduled in 2 weeks to review test results and adjust treatment plan as needed. Patient encouraged to call sooner if palpitations worsen or new symptoms develop.

Built for Primary Care

Scope helps primary care providers manage high patient volumes with comprehensive documentation, chronic disease management tools, and preventive care tracking—all automated.

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Document 30+ patient encounters per day with automated SOAP notes, chronic disease tracking, and preventive care reminders.

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Capture complex medical histories, multiple diagnoses, medication lists, and care plans in seconds—not hours.

Chronic disease management

Track diabetes, hypertension, hyperlipidemia, and other chronic conditions with automated documentation and trend analysis.

Preventive care tracking

Never miss screenings, immunizations, or health maintenance visits with intelligent reminders integrated into your workflow.

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Scope has completely transformed my practice. I'm seeing the same number of patients but finishing notes during the visit instead of staying late. My work-life balance has never been better.

Dr. Lisa Chen, MD

Family Medicine

2.5 hours saved daily

95% same-day note completion

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