Medical Specialty:
General Medicine

Sample Name: Thrombocytopenia - SOAP Note

Description: Patient with immune thrombocytopenia
(Medical Transcription Sample Report)

SUBJECTIVE: I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day. The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.

PHYSICAL EXAMINATION: Vitals: As in chart. The patient is alert, pleasant, and cooperative. She is in no apparent distress. The petechial areas on her legs have resolved.

ASSESSMENT AND PLAN: Patient with improvement of her platelet count on burst of prednisone. We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day. Basically thereafter, over time, I may try to sneak it back a little bit further. She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D. We will arrange to have a CBC drawn weekly.

Keywords: general medicine, platelets, platelet count, thrombocytopenia, prednisone,