medical transcription case study 10 consult
CONSULTATION
Patient Name: J. Randy Rolen
Patient ID: 115037
Consultant: Simon Williams, MD, Pulmonary/Thoracic Surgery
Requesting Physician: Leon Medina, MD, Internal Medicine
Date of Consult: 12/15/XXXX
Reason for Consultation: Continued deterioration with COPD, subcutaneous emphysema, and recurrent pneumothoraxes (ces). Evaluate for possible transfer to Forrest General Medical Center, thoracic unit.
Patient is a 61-year-old white male admitted through the ER with on December 10 with recurrent right pneumothoraxes. Patient is known to have COPD with emphysema and has multiple admissions for problems concerning this. At the time of initial evaluation, a small caliber chest tube was inserted in the anterior axillary line, which improved the patient’s respiratory distress but did not completely resolve the pneumothorax. I was called to the ICU to place a second small caliber chest tube in the posterior axillary line below this. This further improved the patient’s pulmonary status with his saturation improving from 76& to 89%. Since admission he has felt better but complained of pain at the chest tube insertion site. He has continued to leak out through the pleur-evac under water seal, and beginning yesterday he developed subcutaneous emphysema, which has gotten progressively worse. Earlier today he began having increased respiratory difficulty again, with his saturation dropping to approximately 80 % despite oxygen per nasal cannula. Chest x-ray today showed a worsening of the right lower lobe loculated pneumothorax, and on examination today he is not only leaking air through the pleur-evac system but also around the two chest tubes.
PAST HISTORY: Patient has had previous right pneumothorax but never any on the left side. He has undergone some type of attempted pleural ablation therapy. Sputum cultures from this admission have grown Pseudomonas and Streptococcus, and he has been treated with ciprofloxacin. PHYSICAL HISTORY: HR 100,
Patient Name: J. Randy Rolen
Patient ID: 115037
Consultant: Simon Williams, MD, Pulmonary/Thoracic Surgery
Requesting Physician: Leon Medina, MD, Internal Medicine
Date of Consult: 12/15/XXXX
Reason for Consultation: Continued deterioration with COPD, subcutaneous emphysema, and recurrent pneumothoraxes (ces). Evaluate for possible transfer to Forrest General Medical Center, thoracic unit.
Patient is a 61-year-old white male admitted through the ER with on December 10 with recurrent right pneumothoraxes. Patient is known to have COPD with emphysema and has multiple admissions for problems concerning this. At the time of initial evaluation, a small caliber chest tube was inserted in the anterior axillary line, which improved the patient’s respiratory distress but did not completely resolve the pneumothorax. I was called to the ICU to place a second small caliber chest tube in the posterior axillary line below this. This further improved the patient’s pulmonary status with his saturation improving from 76& to 89%. Since admission he has felt better but complained of pain at the chest tube insertion site. He has continued to leak out through the pleur-evac under water seal, and beginning yesterday he developed subcutaneous emphysema, which has gotten progressively worse. Earlier today he began having increased respiratory difficulty again, with his saturation dropping to approximately 80 % despite oxygen per nasal cannula. Chest x-ray today showed a worsening of the right lower lobe loculated pneumothorax, and on examination today he is not only leaking air through the pleur-evac system but also around the two chest tubes.
PAST HISTORY: Patient has had previous right pneumothorax but never any on the left side. He has undergone some type of attempted pleural ablation therapy. Sputum cultures from this admission have grown Pseudomonas and Streptococcus, and he has been treated with ciprofloxacin. PHYSICAL HISTORY: HR 100,