Medical Documentation Proofreading Example 2

Proofreading

The patient is a 69 year old female with history of hysterectomy, who complained of urgency, frequency and stress urinary incontinence. The patient had urodynamics did and a cystoscopy, which reveeled intrinsic sphincter deficiency. Options such as watchful waiting and kegel exercises were discussed. The risks and benefits of all the procedures was discussed. The patient understood, and wanted to proceed with BioArc. Risk of failure of the procedure, recurence of incontinence due to urgency, mesh erosion, exposure, etc, were discussed. The patient understood the risk of infection and wants to proceed with the procedure. The patient was told that due to the intrinsic sphincter deficiency we will try to make the sling a little bit tighter to allow better urethrel closure.



Answer

The patient is a 69-year-old female with a history of hysterectomy, who complained of urgency, frequency, and stress urinary incontinence. The patient had urodynamics done and a cystoscopy, which revealed intrinsic sphincter deficiency. Options such as watchful waiting and Kegel exercises were discussed. The risks and benefits of all the procedures were discussed. The patient understood and wanted to proceed with BioArc. Risk of failure of the procedure, recurrence of incontinence due to urgency, mesh erosion, exposure, etc., were discussed. The patient understood the risk of infection and wanted to proceed with the procedure. The patient was told that due to the intrinsic sphincter deficiency, we will try to make the sling a little bit tighter to allow better urethral closure.


urethral sphincter
Urethral Sphincter:

a muscular structure that regulates the outflow of urine from the bladder into the urethra.

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