Transcript Pulmonary Function Tests

MR250 MEDICAL TRANSCRIPTION I
PULMONOLOGY CHAPTER 10
Week 7
MT Client
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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, MD
ASSISTANT: 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…
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Atalectasis
Adventious sounds
Bronchoiectasis
Barrel chest
Cheyne-Strokes respirations
silia
Crackles
Extubated
Intupation
orthopnea
ANSWER KEY
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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 KEY
1. 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
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ABG
AFB
ARDS
DLCO
EBV
EGFRs
FEV1
FiO2
IMV
PCP
PEEP
PFTs
TLC
ABG=
AFB=
ARDS=
DLCO=
EBV=
EGFRs=
FEV1=
FiO2=
IMV=
PCP=
PEEP=
PFTs=
TLC=
ANSWER KEY
arterial blood gas
acid-fast bacilli
acute respiratory distress syndrome
diffusing capacity for carbon monoxide
Epstein-Barr virus
epidermal growth factor receptors
forced expiratory volume
measured in one second
fraction of inspired oxygen
intermittent mandatory ventilation
Pneumocystis carinii pneumonia
positive end-expiratory pressure
pulmonary function tests
total lung capacity
Respiratory Process Cont.
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4.
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6.
There are six common abnormal lung sound terms heard when
transcribing medical reports list and define them below:
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ANSWER KEY
1.
Rhonchi: loud, coarse, bubbling sounds occurring
over the central airway during inspiration or
expiration that sound like a whistle or a horn.
2.
3.
4.
5.
Wheezes: high-pitched, whistling-type sounds
heard over the large bronchi.
Rales: friction sounds like pieces of sandpaper
being rubbed together.
Grunting: refers to a grunting noises heard during
expiration.
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:
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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 KEY
Pulmonary 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/medicaltranscrip
tionsamples/pulmonary-medicaltranscription-operative-sample-reports
• https://sites.google.com/site/medicaltranscrip
tionsamples/physical-exam-examinationsamples-words-for-medical-transcriptionists
• https://sites.google.com/site/medicaltranscrip
tionsamples/pulmonary-function-test-samplereports
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