Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology
Sample Name: Air Under Diaphragm - Consult

Description: Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Possible free air under the diaphragm.

HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.

PAST MEDICAL HISTORY: Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.

PAST SURGICAL HISTORY: Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.

MEDICATIONS: Unable to evaluate.

ALLERGIES: UNABLE TO EVALUATE.

SOCIAL HISTORY: Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.

REVIEW OF SYSTEMS: Unable to obtain.

PHYSICAL EXAM
VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.
GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.
HEENT: Atraumatic.
NECK: Soft and supple.
LUNGS: Bilaterally diminished.
HEART: Regular.
ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.

LABORATORY STUDIES: Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.

X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.

ASSESSMENT: No intra-abdominal pathology.

PLAN: Have her admitted to the medical service for treatment of her hyponatremia.

Keywords: gastroenterology, free air, hyponatremia, air under the diaphragm, intra abdominal pathology, abdominal, pathology, obtunded, diaphragm,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples