Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Air Under Diaphragm - Consult
Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION:
Possible free air under the diaphragm.HISTORY OF PRESENT ILLNESS:
The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.PAST MEDICAL HISTORY:
Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.PAST SURGICAL HISTORY:
Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.MEDICATIONS:
Unable to evaluate.ALLERGIES:
UNABLE TO EVALUATE.SOCIAL HISTORY:
Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.REVIEW OF SYSTEMS:
Unable to obtain.PHYSICAL EXAM
VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.
GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.
NECK: Soft and supple.
LUNGS: Bilaterally diminished.
ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.LABORATORY STUDIES:
Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.
X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.ASSESSMENT:
No intra-abdominal pathology.PLAN:
Have her admitted to the medical service for treatment of her hyponatremia.
consult - history and phy., free air, hyponatremia, air under the diaphragm, intra abdominal pathology, abdominal, pathology, obtunded, diaphragm,
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