Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Multilobar Pneumonia
Description: Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Loculated left effusion, multilobar pneumonia.
CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female who was admitted to the hospital on 12/22/09 when she had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. Post admission various measures were instituted to address her different manifestations including Cardizem drip. She had rehydration performed and also was given some diuretics. Ultimately there was improvement in her febrile status and renal status. However most recently she had elevated white count and a repeat CAT scan was performed. This showed fluid collection in the left chest but also in the right chest. The left fluid collection was also felt to be loculated. At the same time she was appearing to be quite ill with elevated white count, elevated temperature and for these reasons cardiothoracic consultation was obtained for addressing this fluid collection in the left chest.
PAST MEDICAL HISTORY: Significant for asthma, hypertension and history of pneumonias.
MEDICATIONS: At home she was on Symbicort, ibuprofen, prednisone and Biaxin. Currently she is also on Zyprexa, alcohol withdrawal medications, Zosyn 3.375 grams every eight hours, Lasix 20 mg daily, Cardizem CD 120 mg daily, Nexium 40 mg p.o. daily, Solu-Cortef 50 mg q.24h., Lovenox 40 mg subcu daily, NovoLog sliding scale insulin.
SOCIAL HISTORY: Alcohol drinking history, quit smoking about 30 years ago. The patient is married.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: No remarkable surgical history present. The patient at this time appears confused and the chart review as well as talking to the son revealed most of the history. Apart from recent fevers and confusion the system review is negative.
EXAMINATION: On examination she is lying supine in bed, appears comfortable, awake, alert but is not oriented and is quite confused. Blood pressure is 110/70, heart rate is 80 per minute regular rhythm, saturations are 98 and 99% on four liters nasal cannula. HEENT pupils equal, extraocular movements intact. Sclerae anicteric. Conjunctivae are pink and moist. Neck is supple. Trachea is midline. Thyroid is not enlarged. I did not appreciate any neck masses or neck bruits. Bilateral crackles and rales in the mid lung fields more prominent on the left side and markedly diminished breath sounds especially in the left base. S1, S2 regular rate and rhythm. No murmurs, rubs or gallops. Abdomen is soft, no organomegaly, nontender, normoactive bowel sounds. Extremities do not reveal cyanosis, clubbing or edema. There is 1+ peripheral edema.
LABORATORY DATA: Review of lab data white count 13.4, hemoglobin 8.6 and hematocrit 25, platelet count 317. BUN and creatinine 10 and 0.9. review of CT scan data infiltrate consolidation in multiple lobes of the lung both on the left side as well as at the right base. Right pleural effusion small layering at the base. Left pleural effusion appears to have loculations within the fissure as well as along the chest wall.
IMPRESSION AND PLAN: The patient is a 67-year-old female who is recovering from multilobar pneumonia and is on antibiotics. It appears she has had progression of her disease process in her left chest with now forming loculations. We have been asked to consult for management of this pleural effusion. After discussion with the patient's son who would like to proceed in a step-wise fashion from least invasive to most invasive techniques, I counseled him that we should start with chest tube placement and this should be followed with Activase instillation to try to break up the loculations, pending on the findings on the chest tube placement. If necessary video assisted thoracoscopic procedure or open decortication can be performed.
Keywords: consult - history and phy., neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar,