SOAP / Chart / Progress Notes
Sample Name: URI - SOAP
Description: Sore throat - Upper respiratory infection.
(Medical Transcription Sample Report)
SUBJECTIVE: Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appearing very tired. He is still eating and drinking well, and his voice has been hoarse but no coughing. No shortness of breath, vomiting, diarrhea or abdominal pain.
PAST MEDICAL HISTORY: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.
FAMILY HISTORY: Noncontributory. No one else at home is sick.
General: A 13-year-old male appearing tired but in no acute distress.
Neck: Supple without adenopathy.
HEENT: Ear canals clear. TMs, bilaterally, gray in color. Good light reflex. Oropharynx pink and moist. No erythema or exudate. Some drainage is seen in the posterior pharynx. Nares: Swollen, red. No drainage seen. No sinus tenderness. Eyes are clear.
Lungs: Clear to auscultation throughout.
Heart: Regular rhythm without murmur.
Skin: Warm, dry and pink, moist mucous membranes. No rash.
LABORATORY: Strep test is negative. Strep culture is negative.
RADIOLOGY: Water's View of the sinuses is negative for any sinusitis or acute infection.
ASSESSMENT: Upper respiratory infection.
PLAN: At this point just treat symptomatically. I gave him some samples of Levall for the congestion and as an expectorant. Push fluids and rest. May use ibuprofen or Tylenol for discomfort.
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