SUBJECTIVE: The patient is here for a hospital followup. He was seen actually by Dr. John Doe at the time of hospitalization, at which time he had pneumonia in the right upper lobe, rather extensive. He was discharged on oxygen and nebulizer therapy. He also had lost weight. Since that time, he has quit smoking. He has gained weight. He has a little bit of nonproductive cough, but no chest pain; a little bit of shortness of breath but the O2 is helping. He is using his nebulizer several times a day; although, he did not bring the rest of his medications. He has no other complaints.
OBJECTIVE: The patient is a thin gentleman, in no distress. WT: 128. P: 116. BP: 118/66. RR: 20. Saturations on 1.5 liters 93%. HEENT: He has mild temporal wasting. Pupils are equal and reactive. Nares have no lesions or exudates. There is no dried heme. Oral cavity has no lesions or exudates. Neck: Supple. Cardiac: PMI is not appreciated. Regular, S1/S2. Lungs: He is hyperresonant to percussion. He has moderately diffusely decreased breath sounds with no wheezing or rales. Abdomen: Soft and nontender. Extremities: No edema.
ASSESSMENT: The patient has right upper lobe pneumonia with extensive smoking history and likely chronic obstructive pulmonary disease, shortness of breath, mild cough and hypoxemia.
PLAN: The patient needs a followup chest x-ray to make sure that the infiltrate has cleared. If not, he will need a CT scan. He needs a check of his overnight oximetry and a 6-minute walk on his O2 to assure adequacy of his O2 needs, and he needs PFTs. As we were leaving, his daughter complained of him having some epistaxis. We added humidity to his O2 and gave him saline nasal spray. Follow up after the aforementioned studies, and they understand and agree with the plan.
Pulmonary SOAP Note Medical Transcription Sample Report #2
SUBJECTIVE: The patient is here for a followup. She had her surgery on her shoulder and had it replaced again and is feeling pretty good. She is dyspneic with activity and talking too much. Other than that, she has no new complaints.
OBJECTIVE: WT: She has gained 8 pounds. P: 74. BP: 114/64. RR: 22. Saturations on 3 liters initially 86% and with rest 94%. HEENT: She has no lesions or exudates. Neck: Supple. Lungs: She has mildly decreased breath sounds with no wheezing or rales. Cardiac: Regular, S1/S2. Abdomen: Benign. Extremities: She has +1 ankle edema, and her scar on her right shoulder is healing well.
DIAGNOSTICS: Her chest x-ray from the hospital showed no acute cardiopulmonary disease. She does have COPD, and the right upper lobe infiltrate has resolved.
ASSESSMENT: She has chronic obstructive pulmonary disease with atrial fibrillation, congestive heart failure intermittently with dyspnea, hypoxemia, bronchiectasis, and she is status post shoulder replacement.
PLAN: We told her to follow up with Dr. Jane Doe. We will continue O2. We started her on Spiriva. We told her to hold off on her Atrovent to see how she does with that. We will see her back in 3 months. She knows to call if there is any change in her pulmonary symptoms.
Pulmonary SOAP Note Medical Transcription Sample Report #3
SUBJECTIVE: The patient is here for a followup of her PFTs. She continues to complain of excessive daytime somnolence and fatigue. She said she used to snore but is better on the oxygen therapy. Other than that, she has no new complaints of any kind. She does have achy legs at times.
OBJECTIVE: WT: She has gained a little bit of weight, up to 204 pounds from 198. P: 88. BP: 134/82. RR: 20. Saturations on room air 94%. HEENT: Unchanged from her prior visits. Neck: Supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign, but obese. Extremities: No edema.
DIAGNOSTICS: Her PFTs showed just a very mild decrease in her TLC and FVC from several years ago, and her overnight oximetry on 2 liters shows no significant desaturations.
ASSESSMENT: She has moderate pulmonary hypertension with vocal cord nodules and hoarseness, hiatal hernia, abnormal PFTs, chronic anemia, and known mild obstructive sleep apnea.
PLAN: I am going to recheck her polysomnography to see if there is anything else that could be contributing to her symptoms. If so, then we will intervene on that level. I am going to get a 6-minute walk. I will consider doing a followup CT scan after we recheck her lung volumes in 6 months and follow her a little more closely. She understands and agrees with the plan.
Pulmonary SOAP Note Medical Transcription Sample Report #4
SUBJECTIVE: The patient is here for a hospital followup. She is feeling pretty good. She was hospitalized for shortness of breath, cough and bronchospasm. She did well with inhaled bronchodilators and steroids and was discharged to home in several days. She has had similar episodes, which at times were produced by extreme stress. She took some Advair for a while and then took some Foradil. She has been off of everything for a couple of weeks, and she is feeling pretty good. She is still fatigued, but other than that, she is doing well.
OBJECTIVE: She looks okay. WT: 160. P: 74. BP: 132/70. RR: 18. Saturations on room air 97%. HEENT: She has no lesions or exudates. Neck: Supple without adenopathy. Lungs: Clear to A/P. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.
ASSESSMENT: She has mild asthma with exacerbation of allergic rhinitis, mostly manifesting as a horrific cough and some palpitations also contributing to things.
PLAN: At this point in time, we would like to check some PFTs to see if she needs to be on some type of maintenance therapy. We discussed the rationale of this with her. She understands and agrees, and we will see her back after those.
Pulmonary SOAP Note Medical Transcription Sample Report #5
SUBJECTIVE: The patient is here for a followup. She has found out she is diabetic, but other than that, she is doing well. She occasionally has cough and dyspnea on exertion, but she is doing okay. She has no new complaints at this time.
OBJECTIVE: She looks good. WT: 168. P: 100. BP: 146/76. RR: 18. Saturations on room air 94%. HEENT: Unchanged from her prior visit. Neck: Supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.
DIAGNOSTICS: CT scan shows no changes.
ASSESSMENT: She is status post right upper lobectomy for lung carcinoma T2 versus T3N1M0 with hypoxemia, adenopathy that is unchanged, chronic obstructive pulmonary disease, and a new diagnosis of diabetes mellitus.
PLAN: We will see her back in 6 months, but we will get a CT scan in a year unless the medical oncologist or radiation oncologist would like it sooner.
Pulmonary SOAP Note Medical Transcription Sample Report #6
SUBJECTIVE: The patient is here for followup. He is tolerating the BiPAP. He did well on that. He is complaining of increasing shortness of breath, cough and productive phlegm. He has a little bit of an infiltrate on his chest x-ray. He has no other fevers, chills or sweats. He actually is feeling a little bit better.
OBJECTIVE: WT: 242. P: 62. BP: 128/64. RR: 24. Saturations on room air 93%. HEENT: He has no lesions or thrush. Neck is supple without adenopathy. Lungs: He has a few coarse rhonchi in the right lung. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.
ASSESSMENT: He has right upper lobe pneumonia with abnormal sputum, obstructive sleep apnea with RDI of around 25, history of tracheal stent, coronary artery disease, myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus and peripheral vascular disease.
PLAN: Today, we put him back on his inhaled tobramycin for 2 weeks, Levaquin 500 mg a day for 14 days. We will check a chest x-ray in 2-3 weeks. We will see him back then and then we will readdress his sleep issues, and he will need an overnight oximetry on the BiPAP.
Pulmonary SOAP Note Medical Transcription Sample Report #7
SUBJECTIVE: The patient is here at Dr. John Doe’s request. She has been coughing, short of breath since Friday. She said she got it flared up by someone’s perfume. She was better on Saturday. Today, she is worse again, took some Depo-Medrol 160 mg today. She is coughing. She has no productive phlegm. She has tightness in her chest, and she took some Vantin 200 mg twice a day for 4 days, doxycycline 200 mg twice a day. She was not put on any oral steroids. Her peak expiratory flow rates at home have been greater than 250.
OBJECTIVE: On examination today, she is coughing, dyspneic. WT: She is not weighed. P: 114. BP: Pending. RR: 22. Saturations on room air 97%. HEENT: She has no lesions or thrush. Neck is supple without adenopathy. Lungs: She has mildly decreased breath sounds with an expiratory wheeze. She is moving fairly good air. She has increased respiratory effort. Abdomen: Benign. Extremities: No edema.
ASSESSMENT: She has status asthmaticus with cough, was secondary to her underlying asthma, allergic symptoms, and a prolonged QT. She just saw Dr. Jane Doe today and there is no concern with that.
PLAN: She needs the Vantin, which she will continue for 6 more days. She needs to go home. Her peak expiratory flow in the office was 400 pre-bronchodilator. She is taking a treatment right now. I gave her prednisone burst and taper. I will see her back next week. If her symptoms worsen or she does not improve, she needs to go to the emergency room. She understands that.
Pulmonary SOAP Note Medical Transcription Sample Report #8
SUBJECTIVE: The patient is here for followup. He has a little dyspnea on exertion. We checked his oxygen saturations on room air, and at rest, they are 85%, so he is on his O2. He has no new symptoms or increasing chest pain or cough. He is complaining of allergies and had congestion and sinus pain at times.
OBJECTIVE: On examination, he looks good. WT: 160. P: 96. BP: 104/64. RR: 20. Saturations on room air 94%. HEENT: He has no lesions or exudates. He has deviated septum. Lungs: He has mildly decreased breath sounds but clear. Cardiac: Regular. Abdomen: Benign. Extremities: DJD but no edema.
DIAGNOSTICS: His 6-minute walk showed his room air saturations at rest were 85%.
ASSESSMENT: He has hypoxemia, mild chronic obstructive pulmonary disease, lung carcinoma, non-small cell in the right hilum status post XRT and chemotherapy. He had staging scans again today, and he has chronic sinus disease, and this was seen on the MRI of his brain.
PLAN: We will continue his O2. We put him on Flonase. We will see him back in 4 months. We requested a copy of the scans that were done today.
Pulmonary SOAP Note Medical Transcription Sample Report #9
SUBJECTIVE: The patient is here for followup. She is having a really hard time wearing the CPAP. She knows, but she does not wear it. She has got a headache. She is tired. She wants to sleep on her stomach and it is just not seeming right. She only needs a new mask and she has not done that. We talked for a long period of time about different interventions from surgical to weight loss to repeating the study, all different kinds of options.
OBJECTIVE: WT: 200. P: 80. BP: 138/86. RR: 18. Saturations on room air 95%. HEENT: Unchanged from her last visit. She has a stage III oropharynx. Neck is supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.
ASSESSMENT: She has obstructive sleep apnea with excessive daytime somnolence and tiredness, also some mild cognitive impairment, chronic sinusitis, and temporomandibular joint dysfunction.
PLAN: We reviewed with her surgical options, weight loss of 40 pounds, repeat PSG. She is going to think about all those. In the meantime, we will check an overnight oximetry on room air. She will check for surgeons in her area because she has moved. We will see her back in 8 weeks.
Pulmonary SOAP Note Medical Transcription Sample Report #10
SUBJECTIVE: The patient is here for followup. She is doing pretty good except she threw her back out, and she has been taking some Ultracet for that. It has been helping. She has a little bit of postnasal drip. Her breathing is otherwise unchanged. She does have a little bit of tightness at night. I reviewed her PFTs with her.
OBJECTIVE: WT: 214. P: 86. BP: 140/84. RR: 18. Saturations on room air 97%. HEENT: Unchanged from her prior visits. Neck is supple without adenopathy. Lungs: Clear. Cardiac: S1 and S2. It is irregular. Abdomen: Benign. Extremities: No edema.
ASSESSMENT: She has got mild pulmonary hypertension secondary to mitral stenosis, status post mitral valve replacement with atrial fibrillation. Her PFTs show restrictive impairment with mild asthma, which persists with a good response to bronchodilators.
PLAN: We will check yearly PFTs. I put her on albuterol MDI p.r.n. because of her chest tightness at night, told her to start with 1 puff. I will see her back in 6 months. She knows to call if there is any change in her pulmonary symptoms. I gave her some Ultracet to take as needed for her back pain. She does not want any intervention at this time because she has had that in the past.
Pulmonary SOAP Note Medical Transcription Sample Report #11
SUBJECTIVE: The patient is here for followup. He is actually doing fairly well and overall little bit improved, I think, on even the lower dose of prednisone. This is the best he has felt in a while. He has no new pulmonary complaints.
OBJECTIVE: On exam today, he looks good. WT: 196. P: 72. BP: 170/88. RR: 20. Saturations on room air 96%. With rest, his saturations are at 98%. HEENT: Unchanged from his last visit. Neck is supple. Lungs: He has a few Velcro rales at the bases. Cardiac: Regular. Abdomen: Benign. Extremities: DJD.
ASSESSMENT: He has interstitial lung disease/idiopathic pulmonary fibrosis with bronchiectasis, dyspnea, hypoxemia, and atrial fibrillation.
PLAN: Until the (XX)st of March, we are going to go with the prednisone 10 mg every other day. When he comes back, we will probably check PFTs and a CAT scan. If he gets worse or more short of breath, we told him to go up to one a day. He knows to call if there is any change in his pulmonary symptoms. We will see him back in the fall.
Pulmonary SOAP Note Medical Transcription Sample Report #12
SUBJECTIVE: The patient is here for followup of his polysomnography. He has had really no change since last visit. His wife just continues to complain that he snores quite loudly. He wakes up very frequently. He sleeps on his right side for the most part of time, and he has no other new pulmonary complaints.
OBJECTIVE: WT: 208. P: 72. BP: 126/78. RR: 18. Saturations on room air 95%. HEENT: He has no changes. He has a very small left nasal passage. It is very difficult to visualize. Oral cavity has a stage II-III oropharynx. Neck is supple. Lungs: Clear. Cardiac: Regular. Remainder of his exam is unchanged.
DIAGNOSTICS: His polysomnography showed a very mild OSA with an RDI of 5.7 with mild snoring rated at 5.
IMPRESSION: He has mild obstructive sleep apnea with a deviated nasal passage, history of coronary artery disease, peripheral vascular disease, and according to his wife, he has loud snoring with questionable witnessed apneas.
PLAN: We discussed everything with him. We actually think that he may benefit from an ENT evaluation because of his snoring. He does not really have a lot of symptoms of excessive daytime somnolence and fatigue. To that end, we put a consult into an otorhinolaryngologist who will take his insurance. We put him on some Flonase. We will see him back in 3 months.
