SOAP / Chart / Progress Notes
Sample Name: Q-Fever Endocarditis
Description: A 16-year-old male with Q-fever endocarditis.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.
Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.
VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.
GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.
HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.
NECK: Supple without adenopathy.
CHEST: Clear including the sternal wound.
ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.
EXTREMITIES: Examination of extremities reveals no embolic phenomenon.
SKIN: Free of lesions.
NEUROLOGIC: Grossly within normal limits.
LABORATORY DATA: Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.
IMPRESSION: Q-fever endocarditis.
1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.
2. Repeat Q-fever serology.
3. Comprehensive metabolic panel and CBC.
4. Return to clinic in 4 weeks.
5. Clotting times are being followed by Dr. X.
Keywords: soap / chart / progress notes, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever,