Pulmonary Medical Transcription Consultation Sample Report For Medical Transcriptionists




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.

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.

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.