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: CyberKnife Treatment - Followup

Description: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.

Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.

MEDICATIONS: Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.

PHYSICAL EXAMINATION: BP: 122/86. Temp: 96.8. HR: 79. RR: 26. RAS: 100%.
HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.
NECK: Supple without masses or lymphadenopathy.
LUNGS: Clear to auscultation bilaterally
CARDIAC: Regular rate and rhythm without rubs, murmurs, or gallops.
EXTREMITIES: No cyanosis, clubbing or edema.

ASSESSMENT: The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.

PLAN: She is to return to clinic in three months with a PET CT.

Keywords: soap / chart / progress notes, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,
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