Medical Specialty:
General Medicine

Sample Name: Gen Med SOAP - 3


Description: General Medicine SOAP note.
(Medical Transcription Sample Report)


S: XYZ is in today not feeling well for the last three days. She is a bit sick with bodyaches. She is coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. She is sleeping okay. She does not feel like she needs anything for the cough. She did call in yesterday, and got a refill of her Keflex. She took two Keflex this morning and she is feeling a little bit better now. She is tearful, just tired of feeling ran down.

O: Vital signs as per chart. Respirations 15. Exam: Nontoxic. No acute distress. Alert and oriented. HEENT: TMs are clear bilaterally without erythema or bulging. Clear external canals. Clear tympanic. Conjunctivae are clear. Clear nasal mucosa. Clear oropharynx with moist mucous membranes. NECK is soft and supple without lymphadenopathy. LUNGS are coarse with no severe rhonchi or wheezes. HEART is regular rate and rhythm without murmur. ABDOMEN is soft and nontender.

Chest x-ray reveals no obvious consolidation or infiltrates. We will send the x-ray for over-read.

Influenza test is negative. Rapid strep screen is negative.

A: Bronchitis/URI.

P:
1. Motrin as needed for fever and discomfort.
2. Push fluids.
3. Continue on the Keflex.
4. Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.

Keywords: general medicine, bodyaches, alert and oriented, no acute distress, soap, diarrhea, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented,