Pulmonary Chart Note Medical Transcription Sample Report #1
SUBJECTIVE: The patient returns today in followup for dyspnea on exertion. The patient has been followed by Dr. John Doe in the past for possible pulmonary AVMs, last evaluation was in August. Because of the patient’s history of Osler-Weber-Rendu, he has had an extensive workup including a V/Q study that showed no evidence for significant pulmonary shunt. The patient also had 100% oxygen testing, which revealed a possible shunt of 14%. He also had a transesophageal echocardiogram that suggested the possibility of a pulmonary shunt. The patient went on to have a chest CT angiogram with the AVM protocol, which did not show any evidence of a pulmonary AVM. For the last 3-4 months, he has had occasional episodes where he feels short of breath. Occasionally, this will occur when he is talking. During those episodes, he said, he feels that he needs to take 2-3 deep breaths and then he feels improved. The patient also is very active and participates in an aerobic program. Several times during his aerobic workout, he has once again felt that he needed to take several deep breaths. The patient is able to continue his activity without difficulty.
The patient has no other associated symptoms such as nausea, vomiting, palpitation, diaphoresis, syncope or chest pain. Overall, the patient feels well. He has had no fevers or chills. The patient has had no cough or sputum production. He has had no hemoptysis. He denies any wheezing. He has had no change in bowel or bladder habits. Had no nocturnal shortness of breath.
PAST MEDICAL HISTORY:
1. Osler-Weber-Rendu.
2. Hypercholesterolemia.
3. Osteoporosis and osteoarthritis.
4. History of pulmonary nodules, which have been stable on prior chest CT scans.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Calcium with vitamin D.
2. Vitamin C.
3. Flaxseed oil.
4. Lipitor.
5. Boniva.
SOCIAL HISTORY: The patient is a nonsmoker and does not drink alcohol. No intravenous drug use.
REVIEW OF SYSTEMS: The patient’s weight is stable. All other systems reviewed and were negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing, in no acute distress.
VITAL SIGNS: Blood pressure 130/72, pulse 78, room air oxygen saturation 99%. Height 5 feet 4 inches, weight 140.
HEENT: Head and neck exams were benign. No adenopathy. He did have some small telangiectasia in the posterior buccal mucosa of his oropharynx.
LUNGS: Clear to auscultation and percussion.
CARDIOVASCULAR: Regular rate and rhythm. S1, S2, without murmurs, rubs or gallops.
ABDOMEN: Normal bowel sounds, soft, nontender, without organomegaly or masses.
EXTREMITIES: No clubbing, cyanosis or edema.
DIAGNOSTIC DATA: Personally reviewed chest CT scan, which showed some small nodular densities at the bases, unchanged from prior studies.
IMPRESSION AND PLAN: The patient is a pleasant (XX)-year-old man with a history of Osler-Weber-Rendu syndrome. In the past, the patient has had an extensive workup evaluating him for possible pulmonary AVMs. Based on his most recent chest CT scan, there was no evidence for a pulmonary AVM. The patient is having some mild dyspnea, sometimes at rest and sometimes with activity. At this point, would like to check pulmonary function tests, including trending pulse oximetry, and based upon these studies, consider if he needs any further evaluation.
Pulmonary Chart Note Medical Transcription Sample Report #2
SUBJECTIVE: The patient has a longstanding history of hymenoptera allergy, asthma and COPD and cardiomyopathy. His last 6 months have been very stable. He has had no major flare-ups. He has not had bronchitis or pneumonia. He was stung about a year ago in the summer and experienced no reaction.
He continues to receive injections for wasps and mixed vespid every 8 weeks. He received 0.8 mL of each on May (XX)th for his last injection. He tolerates them well.
His medical regimen includes Advair 250 b.i.d., Spiriva 1 inhalation a day, Allegra 180 once daily, and Singulair 10 mg q.d. He takes Albuterol or Combivent as needed. His other medications are Digoxin, Toprol, lisinopril, furosemide, Glucovance, Actos, Lipitor, aspirin and Centrum Silver.
PHYSICAL EXAMINATION: He is an obese, alert (XX)-year-old male who is in no acute distress. His height is 71 inches, weight 206 pounds and blood pressure 106/54. HEENT: TMs are normal. Nose: Normal appearance of mucosa. Oropharynx: Benign. Eyes: Normal conjunctivae. Neck: No lymphadenopathy or masses. Lungs: Clear. No rales, rhonchi or wheezing. Heart: No murmur. Hearts sounds are very distant. Extremities: No clubbing, cyanosis or edema.
Spirometry: FEV1 was low at 1.15 liters at 34% of predicted but this was better than his baseline of .92 liters at his last visit.
IMPRESSION:
1. Asthma/chronic obstructive pulmonary disease, stable.
2. Cardiomyopathy, stable.
3. Hymenoptera allergy, on venom immunotherapy every 8 weeks.
RECOMMENDATIONS:
1. Continue all current asthma and COPD medications as above with the exception that he should discontinue Combivent and only use Albuterol inhaler for p.r.n. use. The Combivent may interfere with the benefits of Spiriva.
2. Continue venom immunotherapy every 8 weeks.
3. Annual influenza vaccination
4. Routine followup in 6 to 7 months.
