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