Health Record Face Sheet
Record Number: 77-50-77
Age: 76
Gender: Male
Length of Stay: 6 Days
Service Type: Inpatient
Discharge Status: To Home
Diagnosis/Procedure: Hemoptysis
Fiberoptic bronchoscopy with biopsy
DISCHARGE SUMMARY
PATIENT: JARED INPATIENT
RECORD NUMBER: 77-50-77
ADMITTED: 06-15-XX
DISCHARGED: 06-21-XX
PHYSICIAN: DR. ALEX, M.D.
DIAGNOSIS: Hemoptysis.
Hypertension.
Atelectasis.
PROCEDURE: Fiberoptic bronchoscopy x 2 with
biopsy.
HISTORY OF THE PRESENT ILLNESS: The patient is a
76-year-old white male admitted to the hospital with hemoptysis.
The patient states that approximately three weeks ago, he had the
onset of hemoptysis associated with clear sputum. This was not
accompanied by chest pain, fever, or change in his chronic mild
dyspnea. He did not have any pedal edema, PND, or orthopnea
associated with it. He was given prescriptions for Lasix and
Erythromycin when a chest x-ray report returned suggestive of
possible congestive heart failure and/or pneumonia. He states that
since then, his hemoptysis has significantly decreased though it is
still present in the mornings. He is having difficulty feeling
tired all the time but has not had any difficulty with sleep per
se. There is no prior history of pneumonias and no prior history of
CHF. He relates that he had an echocardiogram yesterday, results of
which are unknown. There is no known TB exposure. The patient was
born and raised here in this state.
HOSPITAL COURSE: The patient was admitted and
bronchoscopy was performed to evaluate hemoptysis and rule out
carcinoma. Left lower lobe was collapsed, probably secondary to the
left hemidiaphragm paralysis. There were no other endobronchial
lesions. It should be noted that saturation by oximeter was 85%
before the start of the procedure and before any sedative
mediations were given. On day two of hospitalization, the patient
was given another bronchoscopy with biopsies to work up possible
atelectasis. Prior to the second bronchoscopy the patient was noted
to have multifocal PVCs on the monitor before starting the
procedure. The right sided tracheal bronchial tree was
characterized by prominent changes of chronic inflammation. This
was most impressive in the left lower lobe. The left lower lobe
orifice was narrowed by extrinsic compression. The left lower lobe
segmental orifices were markedly narrow due to extrinsic
compression. Neither the brush nor the transbronchial biopsy
forceps could be passed into the posterior or lateral segmental
orifices. Endobronchial biopsies, brushings and washings were
obtained from the left lower lobe segmental orifices.
DISCHARGE PLANS: The patient was provided home
oxygen, prn. Inhaler prescription was provided along with
instructions. The patient is to follow up in the office in 2
days.
DR. ALEX, M.D.
Electronically authenticated by Dr. Alex, M.D., 06-21- xx
856
HISTORY AND PHYSICAL
PATIENT: JARED INPATIENT
RECORD NUMBER: 77-50-77
ADMITTED: 06-15-XX
DISCHARGED: 06-21-XX
PHYSICIAN: DR. ALEX, M.D.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old white male
admitted to the hospital with hemoptysis. The patient states that
approximately 3 weeks ago, he had the onset of hemoptysis
associated with clear sputum. This was not accompanied by chest
pain, fever, or change in his chronic mild dyspnea. He did not have
any pedal edema, PND, or orthopnea associated with it either. He
was given prescriptions for Lasix and Erythromycin when a chest
x-ray report returned suggestive of possible congestive heart
failure and/or pneumonia. He states that since then, his hemoptysis
has significantly decreased though it is still present in the
mornings. He is having difficulty feeling tired all the time but
has not had any difficulty with sleep per se. There is no prior
history of pneumonias and no prior history of CHF. He relates that
he had an echocardiogram yesterday, results of which are unknown.
There is no known TB exposure.
CURRENT MEDICATIONS: Cardene 20 mg, 1 tid, Lasix 20 mg, 1
qid.
SOCIAL HISTORY: The patient quit smoking 30 years ago after 30
years of one pack per day. He was an engineer with the railroad for
much of his working career. He did some work for a total of about 9
months between 1939 and 1940 in a backroom where there was much
asbestos work being done and he feels that it was
aerosolized.
PAST MEDICAL HISTORY: He has known of high blood pressure for 2 to
3 years. His only prior surgery was an eye removal after an
accident recently.
FAMILY HISTORY: Father died of cancer, one brother died of an MI
and another brother died of cancer.
REVIEW OF SYSTEMS: Negative for kidney disease. Patient has known
previous heart disease, phlebitis, rheumatic fever, hepatitis,
liver disease, or peptic ulcer disease.
PHYSICAL EXAM:
VITAL SIGNS: BP is 180/100 and pulse is 80.
HEENT: Unremarkable with a normal oropharynx.
NECK: Supple without adenopathy or thyromegaly.
CHEST: Has Velcro type rales at the right base. There is dullness
where the left lung base should be. There are only a very few rales
above that region. There are no wheezes heard after
bronchodilator.
ABDOMEN: Soft without tenderness, masses, or
hepatosplenomegaly.
EXTREMITIES: Without clubbing, cyanosis or edema.
LABORATORY DATA: Room air blood gas obtained on the third hospital
day, pH 7.45, PO2 58, PCO2 38. CBC and serum
chemistries were within normal limits.
Spirometry today shows a severe decrease in FVC which is partly
related to air trapping. There is at least mild obstruction. There
was a 53% improvement in FVC after Atrovent treatment.
Chest x-rays are reviewed from one month ago and today. Those from
one month ago showed dense interstitial infiltrate in the right
lung predominant in the mid and lower lung region. There is some
subsegmental atelectasis at the left base above his elevated left
hemidiaphragm. The chest x-ray report from that time notes that
this is probably old and was suggested on a previous upper GI. The
right hilum, I believe is bulky. The heart is enlarged. Film today
shows the vast majority of the infiltrate in the right base has
resolved. The right hilum remains bulky in appearance.
IMPRESSION:
1. Hemoptysis. Resolving right lower lobe infiltrate suggest
probable pneumonia. There may also be some interstitial lung
disease associated with asbestos exposure, as there is persistence
of rales on exam. Congestive heart failure. I am concerned;
however, about the bulky appearance of the right hilum and that
this may have been a post obstructive pneumonia. Furthermore, the
hemoptysis is persisting.
2. Chronic obstructive pulmonary disease and restrictive defect
secondary to elevated hemidiaphragm. As the patient is only very
mildly symptomatic with dyspnea and noticed no symptomatic
improvement Atrovent inhaler is prescribed two puffs q 4 hours on a
prn basis.
PLAN: Bronchoscopy rule out endobronchial neoplasm.
DR. ALEX, M.D.
Electronically signed by Dr. Alex, 06-15-xx, 3345
OPERATIVE REPORT
PATIENT: JARED INPATIENT
RECORD NUMBER: 77-50-77
DATE OF SURGERY: 06-15-XX
SURGEON: DR. ALEX, M.D.
PREOPERATIVE DIAGNOSIS: Hemoptysis.
POSTOPERATIVE DIAGNOSIS: 1. Hemoptysis, probably secondary to
pneumonia.
2. Possible chronic hypoxemia.
OPERATIVE PROCEDURE: Fiberoptic bronchoscopy.
INDICATION: This 76-year-old white male had the onset of hemoptysis
approximately 3-4 weeks ago. A chest x-ray revealed a right lower
lobe infiltrate, left diaphragm paralysis, and signs of possible
congestive heart failure. He was started on Erythromycin and Lasix
with subsequent gradual tapering in the amount of hemoptysis. For
the week prior to today, he has had only one episode. The chest
x-ray showed interval improvement but the right hilum was felt to
be enlarged. He is a former smoker and because the hemoptysis
persisted for such a long period of time bronchoscopy was indicated
to rule out endobronchial abnormality.
DESCRIPTION: The P20 fiberoptic bronchoscope was passed via nasal
approach. The upper airway was normal. The tracheal bronchial tree
was remarkable for quite prominent diffuse changes of chronic
inflammation with linear striations. The segmental orifices of the
left lower lobe were collapsed, probably secondary to the left
hemidiaphragm paralysis. There were no other endobronchial lesions.
It should be noted that saturation by oximeter was 85% before the
start of the procedure and before any sedative mediations were
given.
IMPRESSION:
1. Hemoptysis, probably secondary to pneumonia.
2. Possible chronic hypoxemia.
DR. ALEX, M.D.
Electronically signed by Dr. Alex, 06-15-xx, 3345
OPERATIVE REPORT
PATIENT: JARED INPATIENT
RECORD NUMBER: 77-50-77
DATE OF SURGERY: 06-16-XX
SURGEON: DR. ALEX, M.D.
PREOPERATIVE DIAGNOSIS: Left lower lobe atelectasis.
POSTOPERATIVE DIAGNOSIS: Left lower lobe atelectasis with abnormal
endobronchial findings as described.
OPERATIVE PROCEDURE: Fiberoptic bronchoscopy with endobronchial
biopsies, brushings and washings left lower lobe segmental
INDICATIONS: This 76-year-old white male was
admitted with hemoptysis and is now being evaluated for
atelectasis. CT scan of the chest showed some left lower lobe
atelectasis. Follow up CT scan of the chest showed decrease in the
size of the left lower lobe scan of the chest showed decrease in
the size of the left lower lobe atelectasis which was felt to be
possibly related to an elevated left hemi-diaphragm. Recent repeat
follow up CT scan of the chest showed increase in the amount of
left lower lobe atelectasis and an apparent pleural effusion
associated with it. The patient has not had any new symptoms. He is
felt to have probable asbestosis by his exposure history and
finding pleural plaques and interstitial fibrosis on chest x-ray
and CT scan.
DESCRIPTION: The patient was noted to have
multifocal PVCs on the monitor before starting the procedure and
was therefore pre-medicated with 75 mg of Lidocaine IV. He was also
given 0.5 mg of Versed IV as well as Robinul 0.3 mg IM. A P-20
fiberoptic bronchoscope was passed via nasal approach. The upper
airway was felt to be within normal limits. The right sided
tracheal bronchial tree was characterized by prominent changes of
chronic inflammation. This was most impressive in the left lower
lobe. The left lower lobe orifice was narrowed by extrinsic
compression. The left lower lobe segmental orifices were markedly
narrow due to extrinsic compression. Neither the brush nor the
transbronchial biopsy forceps could be passed into the posterior or
lateral segmental orifices. Endobronchial biopsies, brushings and
washings were obtained from the left lower lobe segmental orifices.
These areas were quite friable. The patient tolerated the procedure
without apparent difficulty and only occasional PVCs were noted
during the procedure. Saturation on room air post procedure is
91%.
PATHOLOGY REPORT RESULTS: Bronchial mucosal fragments, left lower
lobe, showing no diagnostic features.
DR. ALEX, M.D.
Electronically signed by Dr. Alex, 06-16-xx, 3345
List Principal Diagnosis
List Secondary Diagnosis
List Principal Procedure
List Secondary Procedures
The principal diagnosis for this client is,
"Hemoptysis "
The secondary diagnosis includes the following,
The principal procedure for this client is
" Fiberoptic bronchoscopy with biopsy "
The secondary procedure includes following,
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