Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Pulmonary Consultation - 2
Description: Patient with complaints of significant coughing and wheezing.
(Medical Transcription Sample Report)
Thank you very much for referring Mr. Y for pulmonary evaluation. As you know, he is an 85-year-old man who has been referred for complaints of significant coughing and wheezing. The patient was originally seen on 15/02/2008. At that time he was complaining of the same symptoms as well as a recent CBA. The patient had a respiratory evaluation six months ago that was reported to be okay but he still complains of still some difficulty at the time of swallowing. His followup today was done after the patient underwent initial swallowing evaluation. He is still complaining of cough, wheezing, and congestion.
PAST MEDICAL HISTORY: Unremarkable, except for diabetes and atherosclerotic vascular disease.
CURRENT MEDICATIONS: Include Glucovance, Seroquel, Flomax, and Nexium.
PAST SURGICAL HISTORY: Appendectomy and exploratory laparotomy.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a non-smoker. No alcohol abuse. The patient is married with no children.
REVIEW OF SYSTEMS: Significant for an old CVA.
PHYSICAL EXAMINATION: The patient is an elderly male alert and cooperative. Blood pressure 96/60 mmHg. Respirations were 20. Pulse 94. Afebrile. O2 was 94% on room air. HEENT: Normocephalic and atraumatic. Pupils are reactive. Oral mucosa is grossly normal. Neck is supple. Lungs: Decreased breath sounds. Disturbed breath sounds with poor exchange. Heart: Regular rhythm. Abdomen: Soft and nontender. No organomegaly or masses. Extremities: No cyanosis, clubbing, or edema.
LABORATORY DATA: Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid. Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.
1. Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.
2. Old CVA with left hemiparesis.
3. Oropharyngeal dysphagia.
PLAN: At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation. He may use Italian lemon ice during meals to help clear sinuses as well. The patient will follow up with you. If you need any further assistance, do not hesitate to call me.
Keywords: consult - history and phy., pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing,