Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: SOAP - Lung Mass

Description: Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation.
(Medical Transcription Sample Report)

SUBJECTIVE: The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. The patient is doing fairly well. This afternoon, she called me because heart rate was in the range of 120 to 140. The patient is lying down. She does have shortness of breath, but denies any other significant symptoms.

PAST MEDICAL HISTORY: History of mastectomy, chest tube placement, and atrial fibrillation; chronic.

MEDICATIONS:
1. Cardizem, which is changed to 60 mg p.o. t.i.d.
2. Digoxin 0.25 mg daily.
3. Coumadin, adjusted dose.
4. Clindamycin.

PHYSICAL EXAMINATION
VITAL SIGNS: Pulse 122 and blood pressure 102/68.
LUNGS: Air entry decreased.
HEART: PMI is displaced. S1 and S2 are irregular.
ABDOMEN: Soft and nontender.

IMPRESSION:
1. Pulmonary disorder with lung mass.
2. Pleural effusion.
3. Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.

RECOMMENDATIONS:
1. From cardiac standpoint, follow with pulmonary treatment.
2. The patient has an INR of 2.09. She is on anticoagulation. Atrial fibrillation is chronic with the rate increased.

Adjust the medications accordingly as above.

Keywords: cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,
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