PULMONOLOGY SAMPLE REPORTS

LUNG SOUNDS HEARD IN PHYSICAL EXAM

Absent breath sounds
Adventitious breath sounds
Bronchovesicular
Bronchial
Bronchophony
Cavernous breathing
Consolidation
Crackles
Decreased breath sounds
End expiratory phase
Egophony
Grunting
Inspiratory phase
Normal breath sounds
Normal voice transmission
Normal whisper
Pleural friction rub or pleural rub
Rales
Rhonchi
Rhoncus
Sibilant rhonchi
Sonorous rhonchi
Squawk
Stridor
Tracheal
Vesicular breath sounds
Wheezing
Whispering pectoriloquy

PULMONARY FUNCTION TEST

Definitions and Terms used in PFT dictation:

FEV1 - forced expiratory volume 1 - the volume of air that is forcefully exhaled in one second.
FVC - forced vital capacity - the volume of air that can be maximally forcefully exhaled
FEV1/FVC - ratio of FEV1 to FVC, expressed as a percentage
FEF25 - 75 - forced expiratory flow - the average forced expiratory flow during the mid (25 - 75%) portion of the FVC
PEF - peak expiratory flow rate - the peak flow rate during expiration.

SAMPLE BRONCHOSCOPY  REPORTS (DESCRIPTION OF PROCEDURE ONLY)

#1 DESCRIPTION OF THE PROCEDURE:The fiberoptic bronchoscope was inserted through the right nasal passage down through the oropharynx and down to the level of the vocal cords. The hypopharynx was normal. The vocal cords were normal and moved normally towards the midline. The bronchoscope was inserted through the vocal cords into the trachea, which appeared normal. The main carina was sharp and moveable. A systematic examination of all major, lobar, and segmental bronchi was begun. This revealed no endobronchial lesions. Specifically, all of the segmental orifices of the right lower lobe were identified and appeared normal. Under fluoroscopic control, brush biopsies were obtained from the right lower lobe, including the superior segment of the right lower lobe. Transbronchial lung biopsies were obtained from the superior segment of the right lower lobe under fluoroscopic control. Washings were collected from the right lung base. All specimens were submitted for appropriate studies. Afterward, the fiberoptic bronchoscope was removed. The patient appeared to tolerate the procedure well and remained stable following the procedure.

#2 DESCRIPTION OF PROCEDURE:Two liters of oxygen was supplied nasally. The right nostril was anesthetized with two applications of 4% lidocaine and two applications of lidocaine jelly. The posterior pharynx was anesthetized with two applications of Cetacaine spray. The Olympus PF fiberoptic bronchoscope was introduced into the patient's right nostril. The posterior pharynx and epiglottis and vocal cords were normal. The trachea and main carina were normal. The entire tracheobronchial tree was then visually examined and the major airways. No abnormalities were noted on the left side. The entire tracheobronchial tree was then visually examined and the major airways. No abnormalities were noted on the left side. There was, however, extrinsic compression of the posterior segment of the right upper lobe. There also appeared to be submucosal tumor involving the bronchus intermedius between the right upper lobe and right middle lobe. Multiple washings, brushings, and biopsies were taken from the right upper lobe and bronchus intermedius. The specimens were sent for cytology and routine pathology. The patient tolerated this without any complications.

#3 DESCRIPTION OF PROCEDURE IN DETAIL:Following satisfactory topical anesthesia, the Olympus bronchoscope was passed through the right naris and into the posterior oropharynx. The cords were visualized and moved normally. Following the dripping of 1% lidocaine onto the cords, the bronchoscope was inserted into the trachea and examination of the tracheobronchial tree was begun. The carina was midline. The right upper lobe, right middle lobe, and right lower lobe anatomy appeared normal. The left upper lobe, lingula, and left lower lobe anatomy appeared normal. Under fluoroscopy, the right suprahilar area was identified via the apical segment. Bronchial brushings x 2 were obtained for cytology. Bronchial washes were collected for cytology, acid-fast bacilli, and fungus. The patient tolerated the procedure well and following a period of observation, was discharged to home and will be followed up as an outpatient.

#4 PROCEDURE AND FINDINGS:
After adequate anesthesia, the oropharynx and nares were prepared with topical Xylocaine and cocaine. With appropriate hemodynamic monitoring and oxygen supplementation, the Olympus bronchoscope was passed through the right nares into the oropharynx. Erythema of both arytenoid cartilages was noted and this appeared to be superficial. There was no fungating mass. The false cords were normal. The true cords were mildly edematous. The epiglottis was edematous without masses. The cords moved well. There was slight increase in the lymphoid tissue in the periepiglottic area. Anesthesia was given to the cords and the bronchoscope was passed to the trachea. Anesthesia was given to the tracheobronchial tree. The patient had bronchiectatic bronchial segments. They were dilated and one could see multiple subsegmental orifices. Systematic evaluation revealed the right bronchial tree to be normal without mucosal abnormalities of note or endobronchial obstruction. There were areas of hyperpigmentation from previous dust exposure. Under fluoroscopic control, transbronchial biopsies of this left lower lung area were obtained, as well as transbronchial needle aspiration, bronchial brush biopsies and bronchial brush washings for cytology. Sterile brush cultures for culture and sensitivity, acid-fast bacilli, fungus and Legionella were done. The patient tolerated the procedure well.

SAMPLE REPORT - INTUBATION

PREPROCEDURE DIAGNOSIS:
Impending respiratory failure.

POSTPROCEDURE DIAGNOSIS:
Impending respiratory failure.

PROCEDURE PERFORMED:
Endotracheal intubation.

INDICATIONS FOR PROCEDURE:
The patient was hypoxemic and had impending respiratory failure.

DESCRIPTION OF PROCEDURE:
After approximately 2 cc of Xylocaine was instilled into the patient's vocal cords, with appropriate numbing, the patient was given 2 mg of IV Versed, followed by 150 mg of thiopental and subsequently, 60 mg of rocuronium. The patient was easily ventilated via a bag mask. A Mac-3 blade was used to displace the tongue with the tip resting at the vallecula. The vocal cords were clearly visualized with the Mallampati Class II and a #8 endotracheal tube was advanced with the capnometer showing appropriate intubation into the airway after the first time, and the breath sounds were heard bilaterally in the lungs and not in the abdomen. The cuff was inflated and the endotracheal tube was placed at 24 cm. A chest x-ray was done to confirm placement.

COMPLICATIONS:
The patient had an episode of bradycardia and hypotension immediately after intubation.

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Copyright 2005, Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com

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Thank you and May God Bless You,
Rosemarie