SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note
Description: The patient states that he feels sick and weak.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient states that he feels sick and weak.
VITAL SIGNS: Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.
GENERAL: The patient looks tired.
HEENT: Oral mucosa is dry.
CHEST: Clear to auscultation. He states that he has a mild cough, not productive.
CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.
ABDOMEN: Soft and nontender. Bowel sounds are positive. Murphy's sign is negative.
EXTREMITIES: There is no swelling.
LABORATORY DATA: White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000. Glucose is in the low 100s. Comprehensive metabolic panel is unremarkable. UA is negative for infection.
ASSESSMENT AND PLAN:
1. Fever of undetermined origin, probably viral since white count is normal. Would continue current antibiotics empirically.
2. Dehydration. Hydrate the patient.
3. Prostatic hypertrophy. Urologist, Dr. X.
4. DVT prophylaxis with subcutaneous heparin.
Keywords: soap / chart / progress notes, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature,