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: Chest Pain & Respiratory Insufficiency

Description: A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.
(Medical Transcription Sample Report)

Ms. ABCD is a 69-year-old lady, who was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.

We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.

She may continue in the future to have angina and she will have nitroglycerin available for that if needed.

Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d. This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case. She also is on an ACE inhibitor.

So her discharge meds are as follows:
1. Coreg 6.25 mg b.i.d.
2. Simvastatin 40 mg nightly.
3. Lisinopril 5 mg b.i.d.
4. Protonix 40 mg a.m.
5. Aspirin 160 mg a day.
6. Lasix 20 mg b.i.d.
7. Spiriva puff daily.
8. Albuterol p.r.n. q.i.d.
9. Advair 500/50 puff b.i.d.
10. Xopenex q.i.d. and p.r.n.

I will see her in a month to six weeks. She is to follow up with Dr. X before that.

Keywords: soap / chart / progress notes, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic,
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