Pulmonary Case Study

CONSULTATION

This is a 32-year-old white male, lifelong nonsmoker, referred to me.  He complains of a less than 2-week history of dry cough associated with dull substernal discomfort and dyspnea, particularly on exertion.  Otherwise, he has been remarkably free of any other associated symptoms.  In particular, he denies any preceding cold or flu or allergic exposure and denies any associated fevers, chills, sweats, or weight loss.

He does admit to having childhood asthma, but felt he grew out of this by the time he was a teenager.  He has travelled extensively outside the U.S., including travel to the California deserts and Central Valley.  He has not had pneumonia vaccine.  He did have TB skin test 10 years ago and did have flu vaccine 3 years ago.

PAST MEDICAL HISTORY

Past medical history is remarkably negative.

PHYSICAL EXAMINATION

Blood pressure 140/80, pulse 85, respiratory rate 22, temperature 99.3.  Chest examination is completely normal.  There are no rales, wheezes, rhonchi, rubs.  Even on forced exhalation, there was no cough or prolongation.  Cardiac examination showed a regular rate and rhythm with no murmur or gallop.

LABORATORY DATA

PA chest x-ray is striking for a new interstitial infiltrate seen in both midlung zones with some shagging of the cardiac borders, indicating involvement of the lingula and right middle lobe.  Surprisingly, the lowest part of the lung fields and the apices appear to be spared.

Spirometry before and after bronchodilator performed in my office shows a vital capacity of 3.79 or 69% after an 11% improvement with bronchodilator.  FEV-1 achieves 3.24 liters or 72% of predicted after 12% improvement with bronchodilator.  FEV-1/FVC ratio was mildly increased at 85 instead of predicted 82.

ASSESSMENT AND PLAN

Differential diagnoses includes the following

1. Hypersensitivity pneumonitis.

2. Mycoplasma pneumonia.

3. Less likely candidates appear to be Wegener granulomatosis, Goodpasture syndrome, sarcoidosis, alveolar proteinosis, and allergic bronchopulmonary aspergillosis.

RECOMMENDATIONS

1. CBC, differential, chemistry-20, Wintrobe sedimentation rate, angiotensin-converting enzyme, urinalysis, and Mycoplasma titers.

2. Full pulmonary function tests within 2 weeks.

3. Vibramycin 100 mg q.d. for 14 days.

If he still has significant symptoms and restrictions on PFTs within 2 weeks, he will have to be evaluated for one of the more chronic diagnoses, which may ultimately require open lung biopsy.  Otherwise, we should hope that within 2 weeks the patient will be improved and his x-ray will have cleared.

FOOTNOTE

Line 24 (Page 1).  Exam was expanded to Examination.

Line 25 (Page 1).  Temp was expanded to temperature.

Line 33 (Page 1).  Alternative:  Mid lung zone.

Line 3 (Page 2).  The slang term diff was expanded to differential, chem was expanded to chemistry.

Pulmonary Case Study

HISTORY AND PHYSICAL EXAMINATION

This 53-year-old male was evaluated by me in the emergency department on the above date, complaining of progressive shortness of breath and weakness.  He allegedly had been treated some 1 week prior for a right-sided pneumonia, being placed at that time on tetracycline 250 mg q.i.d., promethazine 6.25 mg every 4 hours, and Tylenol 1 every 3 to 4 hours as needed for temperature.  Historically, he has been coughing, nonproductive in nature, and has been experiencing fever and chills.  He had taken a Tylenol approximately an hour and a half prior to this evaluation.  He also has been experiencing poor appetite.

PHYSICAL EXAMINATION

VITAL SIGNS:  Physical assessment reveals his respiratory rate to be 48 per minute, pulse of 112, temperature 99.8, and a blood pressure of 150/80.

GENERAL:  General assessment reveals him to appear somewhat dehydrated, characterized by having dry mucous membranes.

NECK:  There is no nuchal rigidity.

ENT:  Ears, nose, and throat examinations were otherwise unremarkable.

HEART:  His heart rate was regular and rapid without any definite murmurs, S3, or S4.

LUNGS:  Lungs were noted to have rales in the anterior and posterior inferior aspects with decreased breath sounds noted to those areas.  His left lung fields were within normal limits.

ABDOMEN:  His abdomen was soft, nontender, with bowel sounds.

GENITALIA/RECTAL:  Genital and rectal examinations were deleted.

EXTREMITIES:  His extremities were found to be free of any exanthematous changes.  His nail bed color was considered satisfactory.

PLAN

While in the emergency department, multiple diagnostic studies were performed, including a CBC which revealed a white blood count of 18,800, 83 segs, 4 bands, 7 lymphs.  Arterial blood gas revealed a pH of 7.46, PC02 of 40, and a PO2 of 65.  Additional studies pending at this time were a Panel A and a sputum culture and sensitivity.  Chest radiograph obtained and initially interpreted by me revealed consolidative change involving the entire right lower lobe.

IMPRESSION

Right lower lobe pneumonia, refractory to outpatient therapy.

FOOTNOTE

Line 12 (Page 1).  Alternative:  3-4.  Alternative:  Change temperature to fever.  (Technically, everyone has a temperature and Tylenol is taken for a fever.  However, the physician’s use of temperature in the context is perfectly understood.)

Line 18 (Page 1).  The heading Physical Examination was added.

Lines 19-36 (Page 1).  The subheadings were added in the Physical Examination.

Line 27 (Page 1).  The plural forms were changed to singular because there is only one of each.

Line 33 (Page 1).  Exam was changed to examinations for
subject-verb agreement.

Pulmonary Case Study

HISTORY OF PRESENT ILLNESS

Patient is a 1-year-old female who has been congested for several days.  The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago.  Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin cough syrup, and Slo-bid 100 mg b.i.d., but is not improving.  Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

PHYSICAL EXAMINATION

Physical examination in the ER showed an alert child in moderate respiratory distress.  Respiratory rate was 40, pulse 120, temperature 99.6.  HEENT was within normal limits.  Neck was positive for mild-to-moderate stridor.  Chest showed a diffuse inspiratory and expiratory wheezing.  No rales were noted.  Heart showed regular rhythm without murmur, gallop, or rub.  Abdomen was soft, nontender; bowel sounds normal.  Extremities are within normal limits.  Viewing the chest wall, patient had subcostal-intercostal retractions.

The child was sent for a PA and lateral chest x-ray to rule out pneumonia.  No pneumonia was seen on the films.

It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3h.  The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES

1. Acute laryngeal-tracheal bronchitis.

2. Bronchial asthma.

FOOTNOTE

Line 8.  That was changed to who.

Line 10.  He was changed to she.

Line 16.  Exam was expanded to Examination in the report.

Line 30.  The slang term peds was changed to pediatric.

Line 36.  Alternative:  Laryngotracheal.

Pulmonary Case Study

CHART NOTE

The patient first presented with a respiratory infection and a 6-month history of progressive shortness of breath and 35-pound weight loss, and a left lung mass was noted.  Chest x-ray showed a cavitary left lower lobe lung mass, left hilar mass, and left pleural effusion.  CT of the chest showed a mass with mediastinal invasion and adrenal metastases.  He was also noted to have a 10-cm abdominal mass and fine-needle aspiration of this revealed small cell carcinoma, well differentiated.  Bronchoscopy showed an endobronchial lesion with 95% obstruction of the left main stem carina with extrinsic compression of the distal trachea on the left and right, with left vocal cord paralysis.  Cytology was also positive for small cell carcinoma.

             

PHYSICAL EXAMINATION

Vital signs:  Blood pressure 176/90, pulse 96, temperature 96.2, respiratory rate 20 per minute.  Weight 184 pounds.  General:  Well-nourished, well-developed white male in no apparent distress.  Chest:  Decreased breath sounds in the lower one-third of the left lung field with dullness to percussion and end-inspiratory wheezes on the left.  Coronary:  Regular rate and rhythm without gallop or rub.  Grade 2/6 systolic ejection murmur at the lower left sternal border.  Abdomen:  Soft, nontender, bowel sounds present.

DIAGNOSES

1. Extensive small cell carcinoma of the lung.

2. Metastases to the brain, abdomen, adrenals, and mediastinum.

FOOTNOTE

Line 28.  Cor was expanded to coronary for clarity.

Pulmonary Case Study

Dear Sirs,

This is regarding reimbursement of Mrs. (blank) for her prescription medicines.

Her medications at this time include Medrol 4 mg 1 tablet q.d.; Lasix 20 mg a day; Micro-K 10 mEq q.d., #28; as well as Zantac 150 mg p.o. b.i.d., #14; doxycycline 100 mg p.o. q.d. x14 days; verapamil 80 mg, #30; Proventil inhaler 2 puffs q.i.d., 2 inhalers, 6 refills.

All of these drugs are prescription items and are vital to maintenance of her chronic emphysema and its associated cardiac arrhythmias.

Sincerely,

Name.

FOOTNOTE

Line 13.  Re was not dictated but was added to demonstrate proper letter format.

Line 22.  It is necessary to go back and insert the number of pills prescribed, as dictated.