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.
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.
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.
LUNGS: Bilaterally diminished.
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,