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Worsening Dyspnea Consult Medical Transcription Sample




HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old African-American female with no prior pulmonary history, who was admitted with a one-week history of increasing breathlessness and a significant increase in these symptoms over the past one to two days.  The patient notes dyspnea with exertion, minimal activity, worsening significantly over the past several days.  This is not associated with cough, upper respiratory tract infectious symptoms, purulence, chest pain, fever, or wheeze.

1.  Hypertension.
2.  Rheumatoid arthritis.
3.  Spinal stenosis.

1.  Inderal.
2.  Prednisone 5 mg daily.
3.  Vasotec.
4.  KCl.
5.  Motrin.
6.  Arava.
7.  Cardizem.
No oxygen or inhalers are used at home.


SOCIAL HISTORY:  The patient lives with her husband and appears to have supportive children in the area.  The patient is a nonsmoker.  The patient relates description of significant home stress in being the full-time caregiver for her husband.

VITAL SIGNS:  Blood pressure 100/48 mmHg, pulse 62 beats per minute and regular, respirations 18 breaths per minute and nonlabored, and temperature 97.6 degrees.
GENERAL:  This is a well-developed, talkative African-American female, in no acute distress.  She has no shortness of breath noted.
HEENT:  There is no thrush appreciated.  Sclerae anicteric.
NECK:  Supple.  No nodes are found.
HEART:  Heart tones S1 and S2, RRR.  There is a small murmur heard at the sternal border.
CHEST:  Excursion is even, regular, and nonlabored.  There is no accessory muscle use.  Respirations are symmetrical.
LUNGS:  Clear breath sounds to auscultation.  There is no egophony noted.  No wheeze.  ABDOMEN:  Soft and nontender.  No hepatosplenomegaly noted.
EXTREMITIES:  Warm.  No edema.  Pulses are equal bilaterally.

LABORATORY DATA:  Oxygen saturation currently 96% on 2 liters nasal canula O2.  Chest CT, a low probability for pulmonary embolus, although tiny pericardial effusion is found.  The patient also has a 5 mm superior segment right lower lobe mass, which may be granulomatous.  D-dimer is 992, BNP 102, PT 10.6, with INR 1.0.  WBC is 8.8 with hemoglobin 12.2, hematocrit 36.8, and platelets 262,000.  Potassium 3.9, BUN 28, creatinine 1.0, and glucose 108.

1.  Dyspnea.  This patient notes progressive dyspnea with activity, which has worsened over the last several days prior to admission.  Workup shows negative pulmonary origin for this dyspnea at this point; however, she will be followed closely.  Oxygen saturations with activity on room air will be assessed.  If need be, the patient may benefit from outpatient pulmonary stress testing evaluating airflow and oxygenation with simple treadmill stress.  In addition, outpatient pulmonary function testing may be considered.  Nebulized bronchodilators will be continued at this point.
2.  Hypoxemia.  Oxygen will be weaned and oxygen saturations will be assessed.  Arterial blood gas will be drawn if there are any hypoxemic events.
3.  Anxiety.  As noted in her initial history, the patient personally stated that she is under increasing familial stress and wonders if this could be related.  Social service consult will be obtained for further evaluation.
4.  Hypertension.  Blood pressure is now stable.  Stress test results from the hospital would be forwarded.

Thank you, Dr. John Doe, for the opportunity to care for your patient.

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