Medical Transcription Case Study


Patient Name: J. Randy Rolen

Patient ID: 115037

Consultant: Simon Williams, MD, Pulmonary/Thoracic Surgery

Requesting Physician: Leon Medina, MD, Internal Medicine

Date of Consult: 12/15/XXXX

Reason for Consultation: Continued deterioration with COPD, subcutaneous emphysema, and recurrent pneumothoraxes (ces). Evaluate for possible transfer to Forrest General Medical Center, thoracic unit.

Patient is a 61-year-old white male admitted through the ER with on December 10 with recurrent right pneumothoraxes. Patient is known to have COPD with emphysema and has multiple admissions for problems concerning this. At the time of initial evaluation, a small caliber chest tube was inserted in the anterior axillary line, which improved the patient’s respiratory distress but did not completely resolve the pneumothorax. I was called to the ICU to place a second small caliber chest tube in the posterior axillary line below this. This further improved the patient’s pulmonary status with his saturation improving from 76& to 89%.

Since admission he has felt better but complained of pain at the chest tube insertion site. He has continued to leak out through the pleur-evac under water seal, and beginning yesterday he developed subcutaneous emphysema, which has gotten progressively worse. Earlier today he began having increased respiratory difficulty again, with his saturation dropping to approximately 80 % despite oxygen per nasal cannula. Chest x-ray today showed a worsening of the right lower lobe loculated pneumothorax, and on examination today he is not only leaking air through the pleur-evac system but also around the two chest tubes.

PAST HISTORY: Patient has had previous right pneumothorax but never any on the left side. He has undergone some type of attempted pleural ablation therapy. Sputum cultures from this admission have grown Pseudomonas and Streptococcus, and he has been treated with ciprofloxacin.

PHYSICAL HISTORY: HR 100, R 30, and appears moderately uncomfortable and cyanotic.

HEENT: otherwise unremarkable.

CHEST: Breath sounds decreased bilaterally and cannot be heard in the right chest wall because of the crackling sounds from subcutaneous emphysema. Heart tones distant, no murmurs or gallops, rate seems regular.

ABDOMEN: Unremarkable. Extremities: pedal edema is present. There was bubbling from both pleur-evac systems and both chest tubes. When I removed the dressing from the upper chest tube, which was the initial one placed, fell out with the dressing. Patient suddenly became markedly more uncomfortable. There was an escape of air from the chest tube site period. The saturation decreased to 59%. Chest x-ray revealed increased in the pneumothorax from what was seen earlier today, measuring approximately 10%.

IMPRESSION: Bronchopleural fistula with recurrent right pneumothorax.

PLAN: Small caliber chest tubes are not adequate to contain the leakage, and therefore a larger chest tube needs to be placed. If the pleural fistula does not close spontaneously with controlled infection, I would recommend CT scan of the chest and/or bronchoscopy to rule out associated malignancy and consideration of chemical pleurodesis. Once the larger tube was placed, the patient’s status improved. His saturation increased to 94%.

Recommendation: Transfer to Forrest General thoracic unit for evaluation, closure of bronchial pulmonary fistula, and aggressive treatment of patient’s morbid respiratory distress. The patient’s family was notified of the emergent nature of the situation and agreed with the plan.

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