Sample Name: Wasp Sting - SOAP
Description: Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.
(Medical Transcription Sample Report)
SUBJECTIVE: He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past. He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.
Vitals: His temperature is 98.4. Respiratory rate is 18. Weight is 250 pounds.
Extremities: Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow. He says that it is really not painful or anything like that. It is really not all that red and no signs of infection at this time.
ASSESSMENT: Wasp sting to the right wrist area.
1. Solu-Medrol 125 mg IM X 1.
3. Follow up with Dr. XYZ if any further evaluation is needed.
Keywords: dermatology, yellow jacket wasp, wasp sting, swelling, solu-medrol, lot of swelling, stung, sting, wasp,