SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 11
Description: The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to have strep. She was treated with penicillin and sent home. She returned about 8 o'clock after vomiting and a probable seizure. Temperature was 104.5; she was lethargic after that. She had an LP, which was unremarkable. She had blood cultures, which have not grown anything. The CSF has not grown anything at this point.
PHYSICAL EXAMINATION: She is alert, recovering from anesthesia. Head, eyes, ears, nose and throat are unremarkable. Chest is clear to auscultation and percussion. Abdomen is soft. Extremities are unremarkable.
LAB STUDIES: White count in the emergency room was 9.8 with a slight shift. CSF glucose was 68, protein was 16, and there were no cells. The Gram-stain was unremarkable.
ASSESSMENT: I feel that this patient has a febrile seizure.
PLAN: My plan is to readmit the patient to control her temperature and assess her white count. I am going to observe her overnight.
Keywords: soap / chart / progress notes, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure,