Medical Specialty:
Consult - History and Phy.

Sample Name: Pneumothorax & Subcutaneous Emphysema


Description: Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.
(Medical Transcription Sample Report)


REASON FOR CONSULTATION: Pneumothorax and subcutaneous emphysema.

HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice. The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings. The patient was admitted for observation.

PAST SURGICAL HISTORY: Hernia repair and tonsillectomy.

ALLERGIES: Penicillin.

MEDICATIONS: Please see chart.

REVIEW OF SYSTEMS: Not contributory.

PHYSICAL EXAMINATION:
GENERAL: Well developed, well nourished, lying on hospital bed in minimal distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact.
NECK: Supple. Trachea is midline.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds.
EXTREMITIES: No clubbing, edema, or cyanosis.
SKIN: The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.

DIAGNOSTIC STUDIES: As above.

IMPRESSION: The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.

RECOMMENDATIONS: At this time, the CT Surgery service has been consulted and has left recommendations. The patient also is awaiting bronchoscopy per the Pulmonary Service. At this time, there are no General Surgery issues.

Keywords: consult - history and phy., trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema,