Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Evaluation of Allergies

Description: Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.
(Medical Transcription Sample Report)

HISTORY: A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physical and review of systems and detailed medical history.

IMPRESSION:
1. Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.
2. History of fibromyalgia.
3. History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.
4. History of chronic fatigue.
5. History of hypothyroidism.
6. History of depression.
7. History of dysphagia.

RECOMMENDATIONS: RAST allergy testing was ordered for food allergy evaluation. The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested. The patient will follow up after RAST allergy testing for further treatment recommendations. At this point, no changes in her medication were prescribed until her followup visit.

Keywords: soap / chart / progress notes, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy,
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.
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Transcribed Medical Transcription Sample Reports and Examples