SOAP / Chart / Progress Notes
Sample Name: Lung Biopsy Discussion
Description: Patient is here to discuss possible open lung biopsy.
(Medical Transcription Sample Report)
CHART NOTE: She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow. Dr. XYZ had seen her because of her complaints of shortness of breath. Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep. He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy. She was ready to go ahead with this and felt that it was important she find out why she is short of breath. She is very concerned about the findings on her CAT scan and pulmonary function test. She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal. However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function. And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time. After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy. In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed. I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those. And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.
I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it. I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests. And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy. But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her. She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.
We are going to see her back in a month to see how her breathing is doing. We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time. I told her I would try to talk to her sister sometime in the next day or two.
Keywords: soap / chart / progress notes, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonary,