Pediatric SOAP Note Dictation Sample Report

CHIEF COMPLAINT:  Sore throat.

SUBJECTIVE:  The patient is a (XX)-year-old female who presents to the clinic with father due to concerns for sore throat.  The patient states that over the past three days, she has had difficulty with sore throat, runny nose, cough and nasal congestion.  Yesterday, she also had a fever of 101.  Her appetite has been decreased.  She is still maintaining good fluid intake.  No vomiting or diarrhea.  No sick contacts at home; however, she does attend school. Medications included Tylenol during this illness. No known drug allergies.

OBJECTIVE:
VITAL SIGNS:  Temperature 98.2 and weight 51 kg.
GENERAL:  Alert, in no acute distress.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Conjunctivae are clear.  Tympanic membranes are clear bilaterally.  Nares are patent, free of discharge.  Oropharynx has slight erythema.  No tonsillar exudates.
NECK:  Supple with shotty anterior cervical lymphadenopathy.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Benign.
SKIN:  Free of rashes.

LABORATORY DATA:  Rapid strep screen was negative.

ASSESSMENT:  A (XX)-year-old female with viral nasopharyngitis.

PLAN:  A rapid strep screen was performed in the clinic today, which was negative.  We will send this for culture and contact the family with appropriate medical management if it returns positive.  Otherwise, discussed likely viral etiology of illness.  Supportive care measures were reviewed.  The patient and her father were advised about warning signs and to return to clinic if any noted. Otherwise, follow up as needed.

Sample #2

CHIEF COMPLAINT:  Possible eye infection.

SUBJECTIVE:  The patient is an (XX)-year-old female who presents to the clinic with mother due to concerns for possible pinkeye.  Mother states that over the past three to four, her eyes have been watering a lot, and there was a little bit of green discharge.  They also appear slightly red.  Over the past few days, she has also had runny nose and nasal congestion.  The patient denies any fever or coughing.  Overnight, she began complaining of ear pain.  She is still maintaining good oral intake.  No vomiting or diarrhea.  No sick contacts. No routine medications.  No known drug allergies.

OBJECTIVE:
VITAL SIGNS:  Temperature 98.2.  Weight 15.8 kg, height 94 cm.
GENERAL:  Alert, in no acute distress.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Conjunctivae are clear.  She does have some watering of the eyes noted.  Tympanic membrane on the right is erythematous and bulging, left is clear.  Nares are patent, clear rhinorrhea.  Oropharynx is pink and moist.
NECK:  Supple.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Benign.
SKIN:  Free of rashes.

ASSESSMENT:
1.  Right otitis media.
2.  Mild conjunctivitis.
3.  Viral upper respiratory infection.

PLAN:  Recommended beginning the patient on a 10-day course of amoxicillin, 80 mg/kg/day, to treat for her otitis media.  Her conjunctivitis is mild, and we do not believe she will require any topical antibiotics at this time since she will already be on an oral antibiotic.  Discussed continuing supportive care measures and to return to clinic as needed.

Sample #3

CHIEF COMPLAINT:  Fever, congestion.

SUBJECTIVE:  The patient is an (XX)-month-old female who presents to the clinic with a one-day history of fever up to 103 degrees, decreased appetite and increased fussiness.  Mother states that she has had chronic runny nose, nasal congestion and intermittent wet cough for the past four weeks.  The patient does attend daycare, and there have been multiple sick exposures at school.  Mother states that there have been confirmed cases of RSV.  The patient, however, has not had any wheezing, increased work of breathing, vomiting or diarrhea.  The patient is drinking fluids well and maintaining good number of wet diapers.  Medications include Tylenol every 4 to 6 hours as needed and Advil every 6 to 8 hours as needed.  No known drug allergies.

OBJECTIVE:
VITAL SIGNS:  Temperature 98.2, pulse 100, respiratory rate 22, weight 8.3 kg, length 66 cm, oxygen saturation 100% on room air.
GENERAL:  Awake, alert, active infant in no acute distress.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Conjunctivae are clear.  Left TM is erythematous and bulging.  Right TM is slightly erythematous, dull.  Positive nasal congestion.  Throat is nonerythematous.  Mucous membranes are moist.
HEART:  Regular rate and rhythm.
LUNGS:  Clear to auscultation bilaterally with no wheezes.  Good air movement throughout.
ABDOMEN:  Soft, nontender, and nondistended.  Active bowel sounds.
GENITOURINARY:  Erythematous confluent areas with satellite lesions.
EXTREMITIES:  Warm and well perfused.

ASSESSMENT:
1.  Bilateral otitis media.
2.  Prolonged viral upper respiratory infection.
3.  Monilial diaper dermatitis.

PLAN:
1.  For otitis media, we will treat with a 10-day course of cefdinir 125 mg/5 mL half teaspoon by mouth twice a day.
2.  For viral symptoms, recommended continued supportive measures, clearing nasal secretions as needed, encouraging fluid intake, advancing diet slowly as tolerated and Tylenol or ibuprofen as needed for fever or pain.
3.  For monilial dermatitis, prescription was provided for nystatin ointment to apply to affected area three times a day until clear. Recommended airing the patient out of diaper, limiting moisture in this area and using diaper creams in between as needed.
4.  Warning signs were discussed with the mother. Mother is to return with the patient if the patient develops persistent fever, worsening symptoms, respiratory difficulty, poor feeding or for any other concerns.

Central Slip Repair Operative MT Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left index finger central slip avulsion with early boutonniere deformity.
2.  Left long finger proximal interphalangeal joint posttraumatic arthritis, severe.

OPERATION PERFORMED:
1.  Left index finger central slip repair.
2.  Left long finger proximal interphalangeal joint fusion.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

COMPLICATIONS:  None.

TOURNIQUET TIME:  Approximately 115 minutes.

 ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  After informed consent was obtained from the patient, he was taken to the operating room, transferred from the gurney to the operating table, and placed in supine position. General anesthesia was administered, and he was intubated without complication or difficulty. The patient received Ancef 1 gram IV preoperatively for infection prophylaxis. The left upper extremity had a well-padded tourniquet placed in proximal of the left arm. The left arm was then sterilely prepped and draped in the usual fashion.

An Esmarch bandage was used to exsanguinate the left upper extremity, and the tourniquet was inflated to 250 mmHg prior to incision. Using a #15 scalpel blade, a longitudinal incision was first made overlying the PIP joint in dorsal aspect of the left long finger. The radial and ulnar collateral ligaments were taken down, and the PIP joint was evaluated. There were severe osteoarthritic changes with large osteophyte and significant cystic erosion of the joint, both distally and proximally. With a rongeur as well as a bone saw, the bony prominences were taken down and the surfaces refashioned. The surfaces were made to allow fusion at approximately 30- to 35-degree angle of the joint in flexion. An attempt to use Acutrak standard compression cannulated screw to pierce the joint was made. Upon trying to place the screw, after a guidewire was placed, the dorsal cortex of the distal portion of the proximal phalanx cracked and the fixation with the screw was not continued. The screw was removed. We decided to do a K-wire tension banding of the PIP joint. This was performed, and adequate apposition of the joint surfaces and stability was noted. C-arm images confirmed the fixation and alignment of the PIP joint in left long finger in AP and lateral planes in acceptable position. The bony prominences, both radially and ulnarly, were significantly improved. Next, the wound was irrigated with copious amount of sterile normal saline. The extensor tendon mechanism was repaired over the PIP joint and covered with 4-0 Vicryl suture in running and interrupted fashion. The skin edges were reapproximated with 4-0 nylon suture in interrupted horizontal mattress fashion.

Next, attention was directed to the left index finger. A longitudinal incision overlying the PIP joint was made approximately 3 cm in length. Blunt dissection was carried down to subcutaneous tissues developing a skin flap both radially and ulnarly. Small superficial vessels were cauterized with bipolar cautery to derive hemostasis. The extensor mechanism was evaluated in dorsal aspect of the PIP joint. There was evidence of an avulsed fracture at the attachment of the central slip and migration of this fracture approximately 5-6 mm. There was early scar formation and attempted healing in the bed of the fracture site. Using a #15 scalpel blade, a longitudinal incision was made between the lateral bands and the central slip, and the central slip was mobilized to be advanced distally. The fracture bed was debrided back to healthy-appearing bone and the avulsed fracture fragment was also cleaned of any early callus healing. A mini Mitek suture anchor was then placed into the proximal portion of middle phalanx at the fracture site. Using a 0.035 K-wire, two holes were made in the fragment and the sutures from the Mitek suture anchor were passed across the fragment. A Bunnell type of stitch was then placed in the dorsal and proximal portion of the central slip to reinforce the repair. The joint did have a 0.062 K-wire placed across the joint holding in full extension prior to the repair of the central slip avulsion. C-arm images confirmed the alignment of the joint and the re-establishment of the avulsed fragment in its bed in appropriate position in AP and lateral projections. The wound was then irrigated with copious amount of sterile normal saline.

The central slip was then sutured to the lateral bands in its advanced position with 4-0 Vicryl suture in interrupted figure-of-eight fashion, both radially and ulnarly. The skin edges were reapproximated with 4-0 nylon suture in interrupted horizontal mattress fashion. Digital block was performed to both the left index and long fingers with total of 15 mL of half-half mixture of 1% Xylocaine and 0.5% Marcaine without epinephrine to provide postoperative analgesia. Xeroform dressing was placed over the wounds, and sterile 4 x 4 and sterile cast were used to protect the wounds. A well-padded volar splint extending to the tips of the fingers was placed on the left upper extremity incorporating the index and long finger to provide immobilization for early postoperative recovery. It was held in position with light Ace wrap.  General anesthesia was reversed at the conclusion of the case. The patient was extubated and returned to the recovery room in stable condition. Of note, the tourniquet was deflated at approximately 115 minutes of use with adequate perfusion in the left hand after tourniquet deflation with less than 2 seconds capillary refill felt in all digits.

DISPOSITION:  Following observation in the recovery room, the patient will be discharged to home if comfortable and stable. The patient will be instructed for elevation of left upper extremity often at home, avoiding any use of the left hand. The patient is to keep his dressings clean, dry, and intact until his followup in 7 to 10 days. The patient was given Percocet for postoperative pain relief.


Lip Laceration ER Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

 CHIEF COMPLAINT:  Lip laceration and abdominal pain.

 HISTORY OF PRESENT ILLNESS:  This patient is a (XX)-year-old Hispanic female with two complaints. Her first complaint is a lip laceration. She says she was assaulted by her husband two days ago and at that time sustained a lip laceration. She did not seek medical care at that time. She says she has been starting to have increasing pain as well as drainage from that wound. She denies any other injuries from the assault. The second complaint is of abdominal pain. She says she has been having abdominal pain and burning with urination for the last several days and is concerned she may have a STD. She denies any vomiting and denies any diarrhea. She says she is sexually active and does not use protection.

PAST MEDICAL AND SURGICAL HISTORY:  History of schizophrenia.

CURRENT MEDICATIONS:  Cogentin and Prolixin.

ALLERGIES:  She has no known drug allergies.

FAMILY HISTORY:  Unremarkable.

SOCIAL HISTORY:  The patient does admit to smoking two packs of cigarettes a day. Admits to daily ETOH use. Denies any illicit drug use.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  The patient denies fever, chills, dizziness, weakness.
CARDIOVASCULAR:  The patient denies chest pain or palpitations.
RESPIRATORY:  The patient denies shortness of breath or cough.
All other review of systems negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 128/88, pulse 102, respiratory rate 16, temperature 100.4, and O2 sat 100% on room air.
GENERAL:  Well-developed, well-nourished Hispanic female, in no acute distress, appears comfortable lying in bed.
HEENT:  Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. No nystagmus. No scleral icterus. Oral mucosa is moist and pink without erythema or exudate. On the right angle of her upper and lower lips, she has a laceration starting at the vermilion border extending back into the anterior aspect of the oral mucosa that is relatively large. There is purulent drainage present. There is also erythema and induration present, but no fluctuance present. The teeth are normally aligned.
NECK:  Supple with no JVD, no cervical lymphadenopathy noted, no midline C-spine tenderness or step-offs.
RESPIRATORY:  Lungs are clear bilaterally with equal breath sounds.
CARDIAC:  Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES:  No clubbing, cyanosis or edema noted.
GENITOURINARY:  Normal female external genitalia. The patient does have a mild yellowish discharge present from the cervix. The uterus is normal size. There are no adnexal masses or tenderness. There is no cervical motion tenderness.
NEUROLOGIC:  The patient is GCS 15. Cranial nerves II through XII intact. No focal neurological deficits.

EMERGENCY DEPARTMENT COURSE:  The case was discussed with the face surgeons on call, who agreed to follow up with the patient in five days in order to better evaluate the lip. The patient was given 500 mg of Cipro, a gram of azithromycin, and 2 grams of Flagyl while in the emergency department. She was also given two Percocets for her pain, and her tetanus was updated.

MEDICAL DECISION MAKING:  The patient is a middle-aged woman with two complaints. The first complaint is of a lip laceration. She has a rather large lip laceration that would have been primarily repaired if she had come in when she had the initial injury, but at this point, the laceration is large and appears to be infected, so we do not want to close it so that an abscess does not develop. Therefore, at this point, the patient will be covered with antibiotics and will follow up the ENT Clinic on Friday, which is five days from now. As for the patient's second complaint of lower abdominal pain, she does have what appears to be a cervicitis. Her urine also appears to be infected, so we will treat her for a urinary tract infection as well as cervicitis. Her beta hCG was negative.

DIAGNOSES:
1.  Lip laceration with infection.
2.  Urinary tract infection.
3.  Cervicitis.

PLAN:
1.  The patient was given a prescription for Cipro 500 mg p.o. b.i.d. x 6 days.
2.  The patient was given a prescription for clindamycin 300 mg p.o. q.i.d. x 10 days.
3.  The patient was given a prescription for Peridex mouthwash 10 mL swish and spit after meals and before bed.
4.  The patient was given a prescription for Percocet one p.o. q 4 hours p.r.n., total #20.
5.  The patient was instructed to follow up with her primary care physician and follow up with ENT Clinic on Friday.

DISPOSITION:  The patient was discharged home in good condition.

ER Sample Reports     ER Sample Reports # 1

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