MR250 MEDICAL TRANSCRIPTION I PULMONOLOGY CHAPTER 10

Week 7

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PHYSICAL EXAMINATION: Vital Signs:  The patient's temperature is 97.8 degrees, pulse is 74, respirations 19 and blood pressure is 154/96. General:  The patient is awake, alert, in no acute distress.  Pleasant and interactive.  HEENT:  Normocephalic skull.  He has a large laceration to his right temple that is scabbed, not bleeding.  He has ecchymosis around his right eye.  He has a large bruise to the bridge of his nose.  His right eye is swollen shut; he is able to open it.  No subconjunctival hemorrhages.  Pupils equal, round, reactive to light and accommodation.  Sclerae and conjunctivae with no subconjunctival hemorrhages.  Nasal mucosa, turbinates and septum intact with no bleeding or rhinorrhea.  Bilateral tympanic membranes not examined.  Oral mucosa pink, moist and intact.  Small laceration to right upper lip, on the inside.  He does have braces in place.  His teeth appear intact.  Neck:  Supple with no adenopathy.  

PHYSICAL EXAMINATION: Lungs:  Clear to auscultation without wheezing, rales or retractions.  Heart:  Regular rate and rhythm.  Normally split S1 and S2.  No murmur, rub or gallop.  Pulses equal and symmetric in upper and lower extremities.  Abdomen:  Soft, nontender and nondistended with no hepatosplenomegaly.  Bowel sounds are normoactive.  Extremities:  Full active range of motion to left shoulder and left leg.  Full active range of motion of right shoulder; however, he does have some pain with movement/full active range of motion to right knee.  Mother states right knee was swollen yesterday, but today, it does not appear swollen.  Neurologic:  Intact and nonfocal.  Skin:  See HEENT.  Also has large, scabbed abrasion to right calf and ecchymosis to the right shoulder and ecchymosis to the right knee.  Lymphatics:  No cervical, supraclavicular or axillary adenopathy.

Medical Transcription Pulmonary Operative Sample Report # 1: DATE OF PROCEDURE:  PREOPERATIVE DIAGNOSIS:  Subglottic tracheal stenosis.POSTOPERATIVE DIAGNOSIS:  Subglottic tracheal stenosis.PROCEDURE PERFORMED:  Fiberoptic bronchoscopy.SURGEON:  John Doe, MDASSISTANT:  None.INDICATIONS:  Subglottic stenosis.Consent was obtained from the patient prior to procedure after explanation in lay terms the indications, details of procedure, and potential risks and alternatives.  The patient acknowledged and gave consent.MEDICATIONS:  The patient received 50 mcg of fentanyl intravenous, Xylocaine spray to the throat and Xylocaine gel into the nostrils.  A total of 8 mg of Versed was given through the IV; however, her intravenous line had come out at some point early in the procedure and much of the medications did not get to the patient and a new IV line was started prior to initiating the procedure.DESCRIPTION OF PROCEDURE:  The procedure was performed in the endoscopy suite.  The bronchoscope could not be passed easily through either nostril due to narrow nares and the patient's discomfort.  No obvious trauma was caused by trying to pass the scope.  A bite block was placed and the bronchoscope was inserted orally once sufficient sedation was obtained.  The vocal cords were visualized.  The patient appeared to have some right true vocal cord weakness.  The vocal cords did approximate in the midline.  Just below the vocal cords, in the subglottic area, there was scar tissue noted and some mild to moderate narrowing of the upper trachea with almost complete closure of the airway on exhalation.  Pictures were taken of the upper trachea, both on inhalation and exhalation.  Airways were otherwise quickly examined.  The trachea; carina; right upper, middle and lower lobe bronchi; left main stem bronchus and upper and lower lobe bronchi were patent without significant mucosal abnormalities.  Other than associated anxiety, the patient tolerated the procedure well maintaining good oxygen saturation during the procedure and was stable.  On conclusion, no specimens were collected.

Quick Spelling/Proofreading Quiz…• Atalectasis• Adventious sounds• Bronchoiectasis• Barrel chest• Cheyne-Strokes respirations• silia• Crackles• Extubated• Intupation• orthopnea

ANSWER KEY• Atelectasis• Adventitious sounds• Bronchiectasis• Barrel chest• Cheyne-Stokes respirations• Cilia• Crackles• Extubated• Intubation• Orthopnea

Respiratory Process• The exchange of gases between blood in

the systemic capillaries and the cells of the body is called internal respiration. Respiration occurs through 3 processes name and define them.

1. ___________________________2. ___________________________3. ___________________________

ANSWER KEY1. Diffusion, or gas movement through a

semipermeable membrane from an area of greater concentration to one of lesser concentration.

2. Pulmonary effusion, which is blood flow from the right side of the heart, through the pulmonary circulation, into the left side of the heart.

3. Ventilation, which is gas distribution into and out of the lungs.

Respiratory Process Cont.

• Fill in the blanks…

A patient who has _________, or difficulty breathing, may use the ________ of the neck and chest not normally associated with _________, called _________ muscles, to aid in bringing ___ into the ______.

ANSWER KEY

• A patient who has dyspnea, or difficulty breathing, may use the muscles of the neck and chest not normally associated with breathing, called accessory muscles, to aid in bringing air into the lungs.

Respiratory Process Cont.

Orthopnea is discomfort in breathing except in an upright position. You may hear terms such as two-pillow orthopnea or three pillow orthopnea when transcribing what does that mean?

ANSWER KEY

• This describes a patient’s sleeping habits in which the patient requires two or three pillows, respectively, to breathe comfortably while sleeping.

Abbreviations– ABG– AFB– ARDS– DLCO– EBV– EGFRs– FEV1– FiO2– IMV– PCP– PEEP– PFTs– TLC

ANSWER KEYABG= arterial blood gasAFB= acid-fast bacilliARDS= acute respiratory distress syndrome

DLCO= diffusing capacity for carbon monoxide

EBV= Epstein-Barr virusEGFRs= epidermal growth factor receptors

FEV1= forced expiratory volume measured in one second

FiO2= fraction of inspired oxygenIMV= intermittent mandatory ventilationPCP= Pneumocystis carinii pneumoniaPEEP= positive end-expiratory pressurePFTs= pulmonary function testsTLC= total lung capacity

Respiratory Process Cont.There are six common abnormal lung sound terms heard when transcribing medical reports list and define them below:

1. _________________________________2. _________________________________3. _________________________________4. _________________________________5. _________________________________6. _________________________________

ANSWER KEY1. Rhonchi: loud, coarse, bubbling sounds occurring

over the central airway during inspiration or expiration that sound like a whistle or a horn.

2. Wheezes: high-pitched, whistling-type sounds heard over the large bronchi.

3. Rales: friction sounds like pieces of sandpaper being rubbed together.

4. Grunting: refers to a grunting noises heard during expiration.

5. Stridor: a crowing sound heard on inspiration that is caused by air whistling as it passed through swollen upper airways.

Diagnostic Studies & Procedures• Define the words below:

– Pulmonary Function Tests– Spirometer/Spirogram– Tidal volume– Forced vital capacity– Forced expiratory volume– Pulse oximetry– Arterial Blood Gas Test– Peak Flow Monitoring– Ventilation Perfusion Scan

ANSWER KEYPulmonary Function Tests: are a series of

measurements that evaluate the lungs capacity to hold air, move air in and out, and to exchange oxygen and carbon dioxide.

Spirometry/Spirogram/Spirometer: Spirometry is a test that provides measurable feedback about the function of the lungs. Spirogram is a tracing that shows the values of expiratory volumes and flow rates. Spirometer is a device that consists of a small plastic breathing tube hooked to a computerized console that records and prints the data it obtains.

ANSWER KEY Cont.Tidal volume: Indicates the amount of air inhaled or exhaled during normal

breathing.Forced vital capacity: The volume of air that can be forcibly expired forcibly

and quickly after the patient has taken in the deepest breath possible.Forced expiratory volume: The measurement taken when the patient takes

the deepest breath possible and blows into the console's breathing tube, but only the first second of the forced exhalation is recorded.

ANSWER KEY Cont.Pulse oximetry: A noninvasive method of measuring

oxygen saturation in the blood.Arterial Blood Gas Test: A test performed to

determine the amounts of oxygen and carbon dioxide dissolved in the blood, and to ascertain the acid/base status of the blood.

Peak Flow Monitoring: A test that measures the rate of air flow, or how fast air is able to pass through the airways.

Ventilation Perfusion Scan: A scan used to assess distribution of blood flow and ventilation throughout both lungs.

Websites

• https://sites.google.com/site/medicaltranscriptionsamples/pulmonary-medical-transcription-operative-sample-reports

• https://sites.google.com/site/medicaltranscriptionsamples/physical-exam-examination-samples-words-for-medical-transcriptionists

• https://sites.google.com/site/medicaltranscriptionsamples/pulmonary-function-test-sample-reports

Final Thoughts

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