DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Assistance with tracheostomy management.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male transferred to (XX) Hospital on MM/DD/YYYY from (YY) Hospital after an MM/DD/YYYY admission with acute ischemic CVA and DKA. The patient had a very complicated medical history, including respiratory failure, on prolonged mechanical ventilation. He underwent tracheostomy placement on MM/DD/YYYY and shortly thereafter was weaned from mechanical ventilation. He was also diagnosed with hospital-acquired pneumonia, multiorganism, and pulmonary embolism by CTPA. He currently is on heparin drip, while started on Coumadin. He also has end-stage renal disease and is on hemodialysis.
PAST MEDICAL HISTORY: In addition to the above, the patient was found to have some type of intracardiac shunt per echocardiogram, not otherwise defined, atherosclerosis of the internal carotid arteries, positive lupus anticoagulants and long-standing history of diabetes mellitus.
SOCIAL HISTORY: Tobacco and alcohol use are unknown.
MEDICATIONS: Sliding scale insulin, Reglan, Lantus insulin, diltiazem, Timentin, heparin drip, Coumadin, Bactrim, Pepcid and iron sulfate.
ALLERGIES: No known allergies.
REVIEW OF SYSTEMS: Not available.
FAMILY HISTORY: Not available.
PHYSICAL EXAMINATION:
GENERAL: He is an unresponsive male, in no acute distress.
VITAL SIGNS: Temperature is 98.6 degrees; respiratory rate is 21 to 25, somewhat irregular; pulse is 102; blood pressure is 122/80 and pulse oximetry is 97% on 50% cuffless tracheostomy.
HEENT: Unable to visualize posterior pharynx secondary to the patient’s resistance to mouth opening. The patient does have some natural dentition anteriorly. No coating of the tongue is appreciated. The patient has an eschar on the left upper lip, presumably secondary to ET tube. Conjunctivae are clear. Gaze is conjugate. The patient has a size 8 Portex cuffless tracheostomy tube in the midline.
CHEST: The patient has a few crackles at the right base, few anterior coarse rhonchi. No wheeze or stridor with the tracheostomy tube, patent. With finger occlusion of the cuffless #8 Portex, the patient does have stridor and increased respiratory rate. Unable to adequately percuss the chest.
CARDIOVASCULAR: The patient has regular rate and rhythm. No murmur or gallop is appreciated. No heaves or thrills.
ABDOMEN: Soft and obese. The patient has G-tube in position and normoactive bowel sounds. No guarding.
EXTREMITIES: He has decreased pulse in lower extremities bilaterally. No discrepancy in calf size is appreciated. No clubbing, cyanosis or edema. NEUROLOGIC: The patient does withdraw, on the left side, grimaces to pain. He is not cooperative with exam at this time.
LABORATORY DATA: BUN 16 and creatinine 3.3 on MM/DD/YYYY with venous CO2 of 24, calcium 9.1, white count 9200, hemoglobin 9.2 and platelets 515,000. Chest x-ray is not available for review.
IMPRESSION: The patient is a (XX)-year-old male, status post respiratory failure, prolonged mechanical ventilation, necessitating tracheostomy tube placement. He has had multiple complications including pulmonary embolism, for which he is now anticoagulated with heparin and reportedly intracardiac shunt, which would help explain his Aa gradient. He also reported he had a right-sided cavitary lesion and had negative AFB on bronchoalveolar lavage.
RECOMMENDATIONS:
1. Change to #8 Portex cuffless tracheostomy tube. Would not plan on downsizing, capping tracheostomy at this time secondary to poor patient cough, decreased mental status and inability to protect airway. He does have some evidence with occlusion of the tracheostomy of possible upper airway obstruction, and so, if his ability to protect his airway improves, he may need evaluation of the upper airway before considering progressing toward decannulation as well.
2. Repeat chest x-ray to evaluate right cavitary lesion and obtain films from the outside hospital for comparison.
Thank you, for asking me to participate in the care of this patient.
Pulmonary Medical Transcription Consultation Sample Report #2
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: COPD and clearance for colonoscopy.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old pleasant Hispanic male with past medical history of COPD and coronary artery disease, status post coronary artery bypass graft, who was admitted to the hospital with history of rectal bleed. The patient was diagnosed with lower GI bleed and he was scheduled for a colonoscopy. Pulmonary consultation was called for clearance for colonoscopy. Presently, the patient feels better. Mild shortness of breath on exertion, his baseline status. No history of any cough, expectoration, chest pain, nausea, vomiting or diaphoresis.
PAST MEDICAL HISTORY: Significant for COPD, coronary artery disease, status post coronary artery bypass graft, aortic valve replacement, and previous history of bladder tumor.
MEDICATIONS: Presently, he is on Synthroid, Protonix IV, lisinopril, vitamin C, multivitamin, Restoril, Combivent inhaler, albuterol nebulizer, Atrovent nebulizer, and Azmacort.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient had a previous history of smoking about 3 packs per day for 30 years, stopped more than 25 years ago. No history of any alcohol and drug abuse.
FAMILY HISTORY: None pertinent.
REVIEW OF SYSTEMS: As per history of present illness. All other systems are reviewed.
PHYSICAL EXAMINATION: The patient is awake, alert, and oriented x3, not in respiratory distress. His temperature is 99 degrees Fahrenheit, BP is 122/72, respiratory rate is 20, and pulse rate is 90. HEENT: Atraumatic and normocephalic. Ear and nose normal. Heart: S1 and S2. Lungs: Mild decreased breath sounds. No wheezes, no rhonchi. Abdomen: Soft. Bowel sounds are present. Extremities: No cyanosis, clubbing or edema.
DIAGNOSTIC DATA: Chest x-ray, mild interstitial fibrosis.
LABORATORY DATA: WBC count of 8600, hemoglobin 9.2, hematocrit 29.2, and platelets of 212,000. Chemistries: Sodium 136, potassium 4.8, chloride 102, bicarb is 26, glucose 142, BUN of 38, and creatinine 1.6.
IMPRESSION:
1. Acute lower gastrointestinal bleed.
2. Chronic obstructive pulmonary disease.
3. Coronary artery disease, status post coronary artery bypass graft.
4. Previous history of aortic valve replacement.
5. Hypothyroidism.
6. Renal insufficiency.
7. Anemia.
PLAN:
1. We will continue albuterol/Atrovent nebulizer q.i.d. and p.r.n.
2. Azmacort metered-dose inhaler.
3. Follow H&H and transfuse as needed.
4. The patient’s respiratory state is stable for a colonoscopy.
Thank for the consult. We will follow with you.
Pulmonary Medical Transcription Consultation Sample Report #3
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pneumonia.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old pleasant Hispanic female with a past medical history of chronic lymphocytic leukemia, coronary artery disease, who was admitted to the hospital with complaints of mild cough and progressively increasing shortness of breath. The patient denies any history of chest pain, nausea, vomiting or diaphoresis. The patient was evaluated in the emergency department. Her chest x-ray revealed left lower lobe infiltrate and small pleural effusion. Pulmonary consultation was called for further evaluation.
PAST MEDICAL HISTORY: Significant for coronary artery disease, previous history of MI and cardiomyopathy with EF of 25%, hypertension, hyperlipidemia, and chronic lymphocytic leukemia.
MEDICATIONS AT HOME: The patient is on Protonix, Lipitor, Colace, lisinopril, allopurinol, and Coreg.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies history of smoking, alcohol, and/or drug abuse.
FAMILY HISTORY: Not pertinent.
REVIEW OF SYSTEMS: All other systems reviewed.
PHYSICAL EXAMINATION: The patient is awake, alert, oriented, and not in respiratory distress at rest. Her temperature is 98.6, BP is 112/62, respiratory rate is 22, and pulse is 96. HEENT: Atraumatic and normocephalic. Ears and nose are normal. Heart: S1 and S2. Lungs: Few crackles in the left base. No wheezing, no rales. Abdomen: Soft. Bowel sounds are present. Extremities: No cyanosis, clubbing or edema.
LABORATORY DATA: WBC count of 49,600, hemoglobin 8, hematocrit 24, and platelets of 126. Chemistry: Sodium 133, potassium 4.4, chloride 100, glucose 158, BUN 24, and creatinine 1.1.
IMPRESSION:
1. Left lower lobe infiltrate with small pleural effusion, rule out pneumonia, bacterial or atypical to small left pleural effusion, rule out parapneumonic effusion or congestive failure.
2. Coronary disease and cardiomyopathy.
3. Chronic lymphocytic leukemia with anemia.
4. Hypertension.
5. Advanced age.
PLAN:
1. Will continue present pneumonia protocol and IV antibiotic. Check sputum cultures.
2. Transfuse packed red blood cells to keep hemoglobin around 10.
3. Follow up chest x-ray with treatment.
4. Pulmonary toilet.
Pulmonary Medical Transcription Consultation Sample Report #4
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Continuous air leak from the chest tube.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old pleasant Hispanic female who recently underwent a left upper lobe resection for a left-sided mass by Dr. John Doe. The patient had a problem postoperatively and had continuous air leak from the chest tube. The patient was discharged home with a chest tube in place approximately 10 days ago. Her pathology was consistent with adenocarcinoma of the left upper lobe. Her lymph nodes were negative for metastasis.
Yesterday, she started having increasing chest pain and shortness of breath to the point that she came to the emergency department. The chest x-ray performed in the emergency department showed increase in left pneumothorax, approximately 15-20%. Previously, she had a very small pneumothorax at the hospital. The patient is complaining of pain at the site of the chest tube. The patient is also complaining of shortness of breath. The patient denied any cough or sputum production or hemoptysis. No high fever reported.
PAST HISTORY:
1. Breast cancer.
2. Status post left upper lobe resection. Pathology was consistent with adenocarcinoma.
3. Hyperlipidemia.
4. Right-sided mastectomy for breast cancer.
5. Knee surgery.
6. Lumpectomy.
7. Removal of ovarian cyst.
8. Smoking history and COPD.
FAMILY HISTORY: Positive for cancer.
SOCIAL HISTORY: The patient has a 40 pack-year smoking history. She is married and lives with her husband. She quit smoking approximately a year ago.
CURRENT MEDICATIONS: Reviewed. Respiratory wise, she is using Advair 250/50 two times a day and albuterol inhaler. She is not on any oxygen supplementation.
REVIEW OF SYSTEMS: Twelve-point review of systems obtained. No weight loss reported. Her appetite is good, but for the last 1 or 2 days, she is not eating good because of severe pain.
PHYSICAL EXAMINATION:
GENERAL: On examination, the patient is alert, awake, oriented, in no respiratory distress.
VITAL SIGNS: Blood pressure 106/62, pulse 98, respirations 16, and temperature 98.2 degrees. Pulse oximetry 95% on 2 liters.
HEENT: Sclerae anicteric. Conjunctivae pink. No tenderness in maxillary or frontal sinus area.
NECK: No mass, no lymphadenopathy.
CHEST: Decreased air exchange in the left side. Right side, good air exchange with some rhonchi.
HEART: S1 and S2 audible, regular rate and rhythm.
ABDOMEN: Soft, nondistended, and nontender.
EXTREMITIES: No edema, no clubbing, no cyanosis.
LABORATORY DATA: Laboratory work showed WBC count of 17,200, hemoglobin 12.8, platelets of 372,000. INR 1.08. Sodium 136, potassium 3.9, BUN 9, and creatinine 0.8.
IMPRESSION:
1. The patient is a (XX)-year-old female status post left upper lobectomy for adenocarcinoma. The patient has persistent air leak and probably bronchopleural fistula. The patient came with increase in chest pain, shortness of breath, and increase in pneumothorax of the left side.
2. Smoking history and chronic obstructive pulmonary disease.
3. History of breast cancer in the past.
4. Leukocytosis.
RECOMMENDATIONS: We discussed with the ER physician and we recommended placing chest tube with Pleur-evac and with negative suction to help pneumothorax. The patient is feeling better since we placed her on the Pleur-evac. We will repeat chest x-ray to make sure the pneumothorax is resolving. The patient will be started on aerosol treatment. We will give Avelox for possible infectious process; although, clinical suspicion is low. The patient would probably need transfer, to follow up with Dr. John Doe who did the surgery for evaluation and further management of persistent air leak and bronchopleural fistula.
