Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 7
Patient with a three-day history of emesis and a four-day history of diarrhea
(Medical Transcription Sample Report)
The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened. But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad. The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days. He has not had any emesis today. He has urinated this morning. His parents are both concerned because he had a fever of 103 last night. Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis. He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.MEDICATIONS:
He has no known drug allergies.REVIEW OF SYSTEMS:
Negative as far as sore throat, earache, or cough.PHYSICAL EXAMINATION:
General: He is awake and alert, no acute distress.
Vital Signs: Blood pressure: 106/75. Temperature: 99. Pulse: 112. Weight is 54 pounds.
HEENT: His TMs are normal bilaterally. Posterior pharynx is unremarkable.
Neck: Without adenopathy or thyromegaly.
Lungs: Clear to auscultation.
Heart: Regular rate and rhythm without murmur.
Skin: Turgor is intact. His capillary refill is less than 3 seconds.LABORATORY:
White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos. His platelet count on his CBC is 215.ASSESSMENT:
The parents did point out to me a rash that he had on his buttock. There were some small almost pinpoint erythematous patches of papules that have a scab on them. I did not see any evidence of petechiae. Therefore, I just reassured them that this is a viral gastroenteritis. I recommended that they stop giving him juice and just go with the Gatorade and water. He is to stay away from milk products until his diarrhea and stomach upset have calmed down. We talked about BRAT diet and slowly advancing his diet as he tolerates. They have used some Kaopectate, which did not really help with the diarrhea. Otherwise follow up as needed.
soap / chart / progress notes, diarrhea, emesis, history of, gastroenteritis, viral, brat diet, progress note,
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