Sample Name: Trouble breathing
Description: Patient with worsening shortness of breath and cough.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: "Trouble breathing."
HISTORY OF PRESENT ILLNESS: A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.
PAST MEDICAL HISTORY: Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage.
PAST SURGICAL HISTORY: IVC filter placement 1999. Tubal ligation.
FAMILY HISTORY: She reported that her parents were healthy with no known medical problems. She had five healthy children with no medical problems. There was no family history of lung disease, thromboembolism, pulmonary embolism, stroke, or heart disease.
MEDICATIONS: Ibuprofen PRN.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.
Blood pressure: 122/89.
Heart rate: 126 beats per minute.
Respiratory rate: 24 breaths per minute.
Pulse oximetry: 85% on room air.
HEENT: NC/AT, PERRL, EOMI, there was a pink to purplish cyanotic discoloration about the lips, tongue and eyes, the oropharynx was clear with no lesions, the neck was supple, no lymphadenopathy, no JVD, no bruits, the trachea was midline, there was a normal carotid upstroke.
HEART: Tachycardic, regular rhythm, no murmurs, rubs, or gallops. Normal S1 and S2. The PMI was not displaced. No heave.
LUNGS: Bilateral diffuse crackles, no wheeze, no dullness to percussion.
ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding.
EXT: No clubbing, no lower extremity edema or swelling, no palpable cords. Negative Homans’ sign.
NEURO: The patient was alert and oriented times three. Cranial nerves 2-12 were intact. The DTRs were 2+ bilaterally and symmetric. Motor strength and sensation were within normal limits. The cerebellar exam was within normal limits.
LYMPH: No cervical, axillary, or inguinal lymph nodes were present.
SKIN: Warm, dry skin. No rashes, no tattoos.
MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout.
CXR: Single view of the chest revealed increased interstitial density, greatest at the bases bilaterally. The cardiac silhouette and pulmonary vasculature were within normal limits. The osseous structures were normal.
CT CHEST with CONTRAST: The pulmonary artery was well opacified with contrast material and revealed no filling defect. There was extensive increased interstitial density in both the right and left lungs associated with atelectasis in the bilateral bases. There was no pneumothorax or pleural effusion.
ECG: Sinus tachycardia, otherwise normal EKG.
ECHO: The LV was normal in size, wall thickness, and wall motion. The left ventricular systolic function was normal. Estimated EF was 65-69%. The RV was normal in size. The RV systolic function was normal. The left and right atria were normal in size. No intracardiac shunt was present. Trace MR and TR were present. The TR jet was insufficient to assess PA pressures. No pericardial effusion was noted. The transthoracic echocardiogram was interpreted as normal.
HOSPITAL COURSE: The patient was stabilized and was admitted to the telemetry unit on supplemental oxygen. The oxygen saturation increased from 88% to 96% on 6 liters-per-minute supplemental O2. The cultures listed below were obtained, and she was started on intravenous antibiotics to cover empirically for community acquired pneumonia. Given her history, she was initially anticoagulated. The diagnostic studies listed above were carried out. A diagnostic procedure was performed.
Keywords: general medicine, trouble breathing, pulmonary embolism, sinus tachycardia, wall thickness, wall motion, ventricular systolic function, systolic function, intracardiac shunt, systolic function was normal, worsening shortness of breath, shortness of breath, venous thromboembolism, ivc filter, breathing, orthopnea, insidious, embolism, thromboembolism, lymphadenopathy, pulmonary,