chart 140 set 6
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Holy Family University *
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Course
420
Subject
Medicine
Date
Apr 3, 2024
Type
docx
Pages
7
Uploaded by MateRainCaterpillar31
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Chart Readiness – Template for Practice SOAP Notes
1.
Chart #: 2.
Chief Complaint(s): 3.
History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.)
The patient is a 34-year-old woman who presents at the clinic on 01/10/2019 with a persistent and worsening sore throat since 01/01/2019.
She is also experiencing crusting and matting, along with redness (erythema) of the right eye, which started on 01/09/2019.
The patient reports a nocturnal and morning cough, aggravated when lying down. She describes a sensation of having something lodged in her throat and mentions severe throat irritation.
Due to discomfort, she has been sleeping in a recliner for the past two nights.
She has been self-administering Dimetapp, although it's unclear if it provided relief.
The patient also notes experiencing bilateral ear pain with physical activity since giving birth to her second child eight months ago but denies current ear pain. Her husband has pointed out her hearing loss.
There are no known allergies to Sulfa.
The patient is currently breastfeeding.
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4.
Review of Systems: *
Copy/paste the below ROS into your answer and remove/add as necessary. Please only include pertinent findings.
Constitutional: Negative chills, fever, fatigue
HENT: Negative sore throat, congestion, otalgia
Eyes: Negative blurred vision, eye pain/discharge/redness
Respiratory: Negative cough, sputum production, dyspnea, wheezing, hemoptysis
CV: Negative chest pain, DOE, orthopnea GI: Negative abd pain, N/V/D, constipation, hematochezia, melena, heartburn
GU: Negative pelvic pain, dysuria, hematuria, frequency, nocturia
MS: Negative back pain, joint pain, myalgia, limited ROM
Integumentary: Negative rash, erythema, pruritus, abrasion, laceration, postoperative site
Neurological: Negative headache, dizziness, paresthesia, speech change
Psychological: Negative anxiety, depression, suicidal/homicidal ideation, insomnia Endocrine: Negative heat/cold intolerance, hair loss, significant weight gain/loss, polyuria, polydipsia
Hematologic/Lymphatic: Negative easy bleeding, ecchymosis, lymphadenopathy
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HEENT: Positive intermittent sore throat, erythema and matting/crusting of the right eye, and bilateral otalgia with activity. Negative current otalgia. Respiratory: Positive cough.
5.
Past Medical History: (If verbalized during encounter.)
NA
6.
Past Surgical History: (If verbalized during encounter.)
NA
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7.
Social History: (If verbalized during encounter.)
NA
8.
Family History: (If verbalized during encounter.)
NA
9.
Diagnostic Data Discussed:
(Lab work, imaging, EKG, etc. Anything discussed during today’s visit.)
NA
10. Physical Examination *Copy/paste the below PE into your answer and remove/add as necessary. Please only include pertinent findings.
Constitutional: Well-developed, well-nourished
Head: AT/NC
Neck: Supple, full ROM, no masses, no bruit, no JVD
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Eyes: PERRL, EOMI, sclerae anicteric, normal visual fields
ENT: Nose normal, throat clear, no oral lesions, healthy dentition
Cardiovascular: RRR, no murmur or gallop, normal S1 and S2, intact distal pulses
Respiratory: CTAB, normal aeration
Abdomen: Soft, nontender, nondistended, normal bowel sounds, no masses, no organomegaly
Breasts: Bilateral breasts without mass, fullness, or tenderness Back: No tenderness, normal curvature
Extremities: No edema, no muscular or joint tenderness
Lymphatic: No palpable nodes, no adenopathy
Skin: No suspicious lesions identified
Neurological: Speech clear, memory intact, CN II-XII intact, normal coordination, normal gait, 5/5 strength bilaterally, equal sensation bilaterally
Psychiatric: Appropriate, normal judgement
HEENT: Normal uvula, minor erythema. Inflammation of turbinates. Right tympanic membrane bulging with clear fluid. Cardiovascular: Regular rate and rhythm.
Respiratory: Clear to auscultation bilaterally
11. Assessment & Plan
First list diagnosis, then type out the plan. Include any labs ordered. Example: 1.) Breast cancer
Start Arimidex 1mg QD.
Symptoms reviewed/discussed. Ordered: CBC, CMP, CA 15-3, CEA
Follow up in 3 months. 2.) Hypertension
Continue Metoprolol 25mg BID. Encouraged to monitor BP at home three times daily. Bring list of blood pressure readings to next appointment
.
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1. Conjunctivitis, Right Eye:
Prescribed Polytrim ophthalmic drops to be applied in both eyes for one week.
2.Viral Infection with Cough:
Prescribed Fluticasone for one month to alleviate nasal congestion and post-nasal drip. Instructed to administer by spraying into each nostril, targeting the same side ear. Full benefits may be observed within 1-2 weeks.
Prescribed Tussionex for cough relief. Advised to follow a "pump and dump" regimen in the morning if taking Tussionex at night, considering her current breastfeeding status.
3. Hearing loss:
Suggested undergoing a complimentary hearing assessment at Costco. Depending on the results of the hearing test, further evaluation by an audiologist may be recommended.
12. Please list all orders that should be pended for this visit: Include all lab, diagnostic imaging, medications and referrals.
Polytrim drops, fluticasone, Tussionex
13. Scribed for Dr. _____ by _____, medical scribe, on _____ at _____. I, Dr. _____, have personally reviewed and agree with the information entered by the scribe. (Rewrite this sentence in the answer space, filling in the blanks.)
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