SOAP / Chart / Progress Notes
Sample Name: Three-Week Postpartum Checkup
Description: The patient comes for three-week postpartum checkup, complaining of allergies.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: The patient comes for three-week postpartum checkup, complaining of allergies.
HISTORY OF PRESENT ILLNESS: She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.
MEDICATIONS: Prenatal vitamins.
ALLERGIES: She thinks to Benadryl.
FAMILY HISTORY: Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections.
VITALS: Weight: 124 pounds. Blood pressure 96/54. Pulse: 72. Respirations: 16. LMP: 10/18/03. Age: 39.
HEENT: Head is normocephalic. Eyes: EOMs intact. PERRLA. Conjunctiva clear. Fundi: Discs flat, cups normal. No AV nicking, hemorrhage or exudate. Ears: TMs intact. Mouth: No lesion. Throat: No inflammation. She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.
Abdomen: Soft. No masses.
Pelvic: Uterus is involuting.
Rectal: She has one external hemorrhoid which has inflamed. Stool is guaiac negative and using anoscope, no other lesions are identified.
ASSESSMENT/PLAN: Satisfactory three-week postpartum course, seasonal allergies. We will try Patanol eyedrops and Allegra 60 mg twice a day. She was cautioned about the possibility that this may alter her milk supply. She is to drink extra fluids and call if she has problems with that. We will try ProctoFoam HC. For the hemorrhoids, also increase the fiber in her diet. That prescription was written, as well as one for Allegra and Patanol. She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon. She will call and return if she continues to have problems with allergies. Meantime, rechecking in three weeks for her final six-week postpartum checkup.
Keywords: soap / chart / progress notes, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,