Medical Transcription Audio & SOAP Report 1

What follows is a medical transcription report of a doctor-patient clinic-visit conversation. The YouTube video below will play the transcription audio. You need to open your typing software, then play the audio, and then take down what you hear. Once finished, you can check out the original transcription below and see if they match up.






Fargoz United Health Care

Specialty: Allergy/Immunology
Date: January 1, 2024
Doctor: Mr. Fargoz

Patient's name: Mr. Robert
Patient's ID: fgu123456

SUBJECTIVE

This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.

Current medication: Ortho Tri-Cyclen and the Allegra.

Allergies: She has no known medicine allergies.

OBJECTIVE

Vitals: Blood pressure 124/78.

Constitution: Weight was 130 pounds.

HEENT: Her throat was mildly erythematous without exudate. Nasal mucosa was erythematous and swollen. Only clear drainage was seen. TMs were clear.

Neck: Supple without adenopathy.

Lungs: Clear.

ASSESSMENT

Allergic rhinitis.

PLAN:

1. She will try Zyrtec instead of Allegra again. Another option will be to use loratadine. She does not think she has prescription coverage so that might be cheaper.
2. Samples of Nasonex two sprays in each nostril given for three weeks. A prescription was written as well.


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