Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Progress Note - Supraglottitis

Description: Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.
(Medical Transcription Sample Report)

HISTORY: A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. Please refer to chart for history and physical and review of systems and medical record.

PROCEDURES PERFORMED: Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver. No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.

IMPRESSION:
1. Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.
2. Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.
3. Hypercholesterolemia.
4. History of anxiety.
5. History of coronary artery disease.
6. Hypertension.

RECOMMENDATIONS: Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X. Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation. I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.

Keywords: soap / chart / progress notes, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples