SUBJECTIVE: The patient returns today in followup for severe chronic obstructive pulmonary disease. She was hospitalized in August for pneumonia and influenza. She was discharged to an inpatient pulmonary rehabilitation program. She continues to have shortness of breath with minimal activity, such as walking to the bathroom. She has had a rare cough. She has had no hemoptysis. She has occasional wheezing. She has had no fevers, chills, or sweats. She has had no chest pain. She continues on oxygen 2 liters per nasal cannula at rest and 3 with activity. She has been using DuoNeb 2 to 3 times per day. She has been using Combivent 2 to 3 times per day. She has had no nocturnal shortness of breath. She feels that she has had a slight improvement in her dyspnea. She continues to have fatigue.
PAST MEDICAL HISTORY:
1. Severe chronic obstructive pulmonary disease, on supplemental oxygen.
2. Allergic rhinitis.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. Hypothyroidism.
6. Hyperlipidemia.
MEDICATIONS: Levoxyl, Advair 500/50 mcg one puff twice a day, DuoNeb 2 to 3 times a day p.r.n., Combivent 2 to 3 times per day p.r.n., albuterol p.r.n., Singulair 10 mg a day, Lipitor, lorazepam as needed, Nexium, and prednisone 10 mg per day.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: The patient’s weight is stable. She has had generalized fatigue. All other systems were reviewed and were negative.
OBJECTIVE: Elderly female, in a wheelchair, in no acute distress. Blood pressure 144/78, pulse 92, O2 saturation on 2 liters nasal cannula oxygen 94%. Head and neck exam benign. Lungs had diminished breath sounds bilaterally without wheezing. Heart had regular rate and rhythm, S1, S2. Extremities revealed no clubbing, cyanosis or edema.
DIAGNOSTIC STUDIES: We personally reviewed her chest x-ray, lateral and PA view, and compared it to her previous films. There was clearing of the bilateral lower lobe infiltrates and persistent hyperinflation.
ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old woman with a history of severe chronic obstructive pulmonary disease. She continues to be symptomatic. I would like her to continue on her current nebulizer treatments and Advair. She is going to decrease her prednisone to 10 mg alternating with 5 mg every other day for 2 weeks and then go down to 5 mg a day. We have recommended that she use her DuoNeb or Combivent at least 4 times per day. I would like to see her in 3 months for followup.
Pulmonary SOAP Note Medical Transcription Sample #2
SUBJECTIVE: The patient is a (XX)-year-old gentleman who is followed in the pulmonary clinic for history of sleep apnea and abnormal CT scan. Since he was last seen, he has been using his VPAP on a nightly basis for an average of 6 hours per night. He has tolerated this quite well. He denies any arousals secondary to coughing, gagging, shortness of breath. He will have rare arousals with nocturia. He states, in general, he is doing quite well, and his energy level during the day is much better. He denies any fevers or chills. No cough. No shortness of breath, dyspnea or exertion. No diaphoresis or weight change.
OBJECTIVE: Weight 194 pounds. Blood pressure 126/82, heart rate 80, O2 saturation 94% on room air. In general, the patient is awake, alert, in no acute distress. Breathing comfortably, speaking in full sentences. No cervical or axillary lymphadenopathy. Chest is bilaterally clear. Heart has regular rhythm and rate, no murmur. Abdomen is soft, nontender, nondistended. Extremities revealed no cyanosis, clubbing or edema.
ASSESSMENT AND PLAN:
1. Sleep apnea. The patient is doing quite well with the VPAP.
2. Abnormal CT scan. The patient has a CT scan scheduled. He has no symptoms at this time.
