SOAP / Chart / Progress Notes
Sample Name: Fifth Disease - SOAP
Description: Fifth disease with sinusitis
(Medical Transcription Sample Report)
SUBJECTIVE: Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school. She says it itches and they have been doing some Benadryl for this. She has not had any wheezing lately and is not taking any ongoing medications for her asthma.
PAST MEDICAL HISTORY: Asthma and allergies.
FAMILY HISTORY: Sister is dizzy but no other acute illnesses.
General: The patient is an 11-year-old female. Alert and cooperative. No acute distress.
Neck: Supple without adenopathy.
HEENT: Ear canals clear. TMs, bilaterally, gray in color and good light reflex. Oropharynx is pink and moist. No erythema or exudates. She has postnasal discharge. Nares are swollen and red. Purulent discharge in the posterior turbinates. Both maxillary sinuses are tender. She has some mild tenderness in the left frontal sinus. Eyes are puffy and she has dark circles.
Lungs: Clear to auscultation throughout.
Heart: Regular rhythm without murmur.
Skin: Warm, dry and pink. Moist mucous membranes. Red, lacey rash from the wrists to the elbows, both sides. It is very faint on the lower back and she has reddened cheeks, as well.
ASSESSMENT: Fifth disease with sinusitis.
PLAN: Omnicef 300 mg daily for 10 days. May use some Zyrtec for the itching. Samples are given.
Keywords: soap / chart / progress notes, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx,