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Pulmonary Consultation Medical Transcription Transcribed Sample Report




HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who is status post coronary artery bypass grafting x5 vessels.  He is orally intubated and sedated and pulmonary consultation is requested.  History was obtained from chart review.  The patient began to have chest pain, which occurred mostly at rest.  He saw his primary care physician who did an EKG, which was abnormal.  He was referred to Dr. Doe who did a stress test, which was also abnormal and he underwent cardiac catheterization.  He was noted to have significant disease in his left main.  He had a 70% stenosis in the left anterior descending, 100% stenosis in his right coronary artery and significant disease in the circumflex.  Consultation was obtained with Dr. Doe.  He was found to be an acceptable candidate and he was taken to the operating room, where he underwent coronary artery bypass grafting x5 vessels.  He received a left internal mammary artery to the left anterior descending, saphenous vein graft to the ramus, saphenous vein graft to the obtuse marginal and a saphenous vein graft to the PDA branch sequentially to the posterolateral obtuse marginal branch of the right coronary artery.

PAST MEDICAL HISTORY:  The patient has coronary artery disease as described above.  In record review, there is no history of COPD, but the patient did smoke up until recently.  He does have a history of diabetes mellitus, hyperlipidemia and hypertension.  There is a history of gastritis but no GI ulcers or GI bleeding.  There is no history on the chart of kidney problems, stroke or cancer.

PAST SURGICAL HISTORY:  The patient is status post coronary artery bypass grafting x5 vessels with the left internal mammary artery to the left anterior descending and saphenous vein graft to the ramus and saphenous vein graft to the obtuse margin and a saphenous vein graft to the PDA and sequentially to the PLOM branch to the right coronary artery.

FAMILY HISTORY:  Positive for coronary artery disease.

SOCIAL HISTORY:  The patient smoked 2 packs of cigarettes a day for approximately 20 years and just recently quit.  He only uses alcohol on a rare occasion and the patient was fairly active according to the records, where he walked 6 miles 5 days a week.

REVIEW OF SYSTEMS:  Unable to be obtained secondary to the patient being orally intubated and sedated.


HOME MEDICATIONS:  Diovan, Lexapro, Avandia, lisinopril 20 mg, insulin and Starlix.

GENERAL:  This is a male who is orally intubated and sedated.
VITAL SIGNS:  Temperature 98.6, pulse 96, respirations 22 and blood pressure 94/46, CVP 14, PA 33/19, cardiac output/cardiac index is 4.7/2.2, and SVR is 822.
HEENT:  Pupils are equal and reactive to light and accommodation.
NECK:  Supple.  No JVD, lymphadenopathy or thyromegaly is noted.  Carotid bruits were not assessed secondary to lines and dressings.
CHEST:  Symmetrical.  There is air leak noted in the chest tube; it has drained approximately 550 mL since coming out of surgery.  Sternal dressing is dry and intact.  The patient does have some oozing from his sternal dressing.
LUNGS:  Coarse breath sounds.
HEART:  PMI is not felt.  S1 is normal.  S2 is normally split.  No murmur, gallop or click is noted.
ABDOMEN:  Obese, soft, elastic, nontender and nondistended.  No bowel sounds are noted.  Liver and spleen are not palpable.  No abdominal bruits are noted.
GENITOURINARY:  The patient is noted to have good urinary output.
RECTAL:  Deferred.
EXTREMITIES:  No edema, clubbing or cyanosis is noted.
CENTRAL NERVOUS SYSTEM:  Not assessed secondary to the patient being orally intubated and sedated.

DIAGNOSTIC DATA:  Chest x-ray demonstrates ET and Swan in good position.  No pneumothorax is noted.  The patient does have bibasilar atelectasis.  The patient is orally intubated on FiO2 of 80%, PEEP of 5 and pressure support of 10, rate of 10 and a tidal volume of 960.  ABG demonstrates a pH of 7.32, PCO2 of 42.8, PO2 of 298, base excess of -4 and bicarbonate of 21.6.  EKG demonstrates normal sinus rhythm with nonspecific T-wave abnormality.

LABORATORY DATA:  Sodium 138, potassium 3.6, chloride 110, CO2 of 26, BUN 28, and creatinine 1.2.  INR of 1.36.  WBC of 19.2, platelet count 119,000, hemoglobin 11.8, and hematocrit 34.8.  His activated clotting time is noted to be 700.

1.  Respiratory failure.
2.  Coronary artery disease, status post coronary artery bypass grafting x5 vessels.
3.  Hypertension.
4.  Hyperlipidemia.
5.  Diabetes mellitus.
6.  Renal insufficiency.
7.  Leukocytosis.
8.  Tobacco abuse.
9.  Rule out sleep apnea.

1.  Will wean the patient's ventilator to an FiO2 of 40%, IMV of 4, PEEP of 5 and pressure support of 10.  We will obtain ABG and mechanics, and if acceptable, we will extubate the patient.
2.  Secondary to the patient's long smoking history, we will begin bronchodilators and aggressive pulmonary toilet.
3.  We will obtain a followup chest x-ray in the a.m.
4.  The patient is noted to have leukocytosis.  We will obtain a CBC and basic metabolic panel in the morning.
5.  The patient's ACT is noted to be elevated and we will correct his coags as necessary.
6.  It appears from record review and examination that the patient has risk factors for sleep apnea.  We will obtain night oximetry prior to discharge.

Further recommendations will be made based on the patient's hospital course.  Thank you very much for allowing me to participate in the care of your patient.  I will follow the patient along with you.

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