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Showing posts from December, 2023

Medical Transcription Audio & SOAP Report 1

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What follows is a medical transcription report of a doctor-patient clinic-visit conversation. The YouTube video below will play the transcription audio. You need to open your typing software, then play the audio, and then take down what you hear. Once finished, you can check out the original transcription below and see if they match up. Fargoz United Health Care Specialty: Allergy/Immunology Date: January 1, 2024 Doctor: Mr. Fargoz Patient's name: Mr. Robert Patient's ID: fgu123456

Medical Documentation Proofreading Example 12

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Proofreading The patient is a 40-year-old female with past medical history from repair of deviated septum by  complication of a Septal perforation. At that time, the patient says that her septal perforation  bother her as she feels that she has very dry air trough her nose as well as occasional epistaxis.  At this time I counselled the patient on the risks and benefits of surgery. She will consider surgery  but at this time, she will like two continue using the saline nasal wash as well as occasional  Bactroban to the nose if there are occasional irritation and crusting which she will apply with the  edge of an Q-tip. We will see her back in three weeks. If the patient does not feel releived from  the Bactroban as well as saline nasalspray wash, we will consider setting the patients for surgery  at this time. Answer The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient stat

Medical Documentation Proofreading Example 11

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Proofreading This patient present two the office today dew to some problems with her right hand. It had been tingling  and getting numb periodicaly over the past several weeks. She is worried about carpel tunnel. She does  lot of repetitive type activities. It is worse at night. It involve mostly the middle finger, although she says it  also involves the first and second digit on the right hand. She has some pain on her thumb as well. She  thinks that could be arthritis. The patient is going to use Anaprox double strength one pills every 12 hours  with food as well as a cock-up Wrist splint. We are going to try this for two weeks, and if condition is still  present then we are going to proceed with EMG test at that time. He is working on diet and exercise and  she is doing a great job. Right now, for the blood pressure we are going to continue to observe as she  carries forward addition measures in her diet or exercise for lose more weight, and I expect the  bloodpressure will continue

Natural Calamities - Intermediate Essay 3

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Nature means the total physical world of the earth. It includes elements like plants, water bodies, hills, animals, etc. Only the earth has such a diverse nature. All kinds of living entities, including human beings, animals, and insects, need a friendly nature to sustain their lives. However, recently, the earth has witnessed more natural calamities than in the past. In this essay, I would like to discuss the different kinds of natural calamities and the solutions and remedies for them. A natural calamity is a dangerous phenomenon happening in nature; it causes fatalities to the lives and properties of living entities, mainly human beings. There are several types of natural calamities. Earthquakes are the phenomenon of the earth shaking its surface. In a tsunami, the ocean water swallows the land. Landslides are incidents in which hills collapse along with a gush of water. To add another example, a wildfire refers to the mass burning of forest plants. The list contains even more cala

Medical Documentation Proofreading Example 10

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Proofreading This 34-year-old gentlemen woke up this morning noting some itchiness on his back and then within very  short period of time, realised that he had itchy rash all over his torso and arms. He deny facial swelling,  tongue and lip swelling. He has no shortness off breath, wheezing, and other associate symptom. He  cannot think of anything that could have triggered this. There has been no changes in his food,  medications, or other exposures as for as he knows. He tells a couple of days ago, while at work, he was  removing some insulation, but does not remember feeling itch that day. At the meantime, he can be  managed with some antihistamine tablets. He was responding already to Benadryl and epinephrine that  we gave him here. He is told that if he developed any respiratory complaints, shortness of breath,  wheezing, or tongue or lip swelling, he will return immediately for evaluation. He is discharged in a stable  condition. Answer This 34-year-old gentleman woke up this mo

Medical Documentation Proofreading Example 9

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Proofreading The patient is a 54 year old super obese man, who present today upon referrel from primary care physician. His obesity begun at the age 20 with a weght of 250 pounds, and currently has highest weight. Consultation requested four the evaluation of morbid obesity, and consideration of treatment with bariatric surgery. We have considered surgical weight-loss in hopes of reducing or eliminate this comorbid conditions. He is interested with surgical weight loss particularly gastric bypass surgery. He will followup with a visit in three week. VITAL SIGNS: Pulse 72, respirations 16, blood pressure 134/74, Height 5 feet, 6 inches, weight 324 pounds. BMI 52.3.   Answers The patient is a 54-year-old super-obese man, who presents today upon referral from primary care physician. His obesity began at the age of 20 with a weight of 250 pounds and currently has the highest weight. Consultation requested for the evaluation of morbid obesi ty an d consideration of treatment with bariat

Medical Documentation Proofreading Example 8

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Proofreading The patient is a 49 year old white female, who lost come to the clinic at 15/10/2021. He comes in today for a re evaluation of her acne, plus she has had what she call a rash for the past two month now on her chest, stomack, neck and back. The patient is well-developed and appear stated age. At examination, there is flaring of her acne with small folliculits lesions. The patient have been taking Amoxicillin 500 mg bid. and using Tazorac cream 0.1. Her face is doing well, but she has been out of her meditation now since three days also. She is been getting photofacials at Healing waters. She is to continuing Tazorac cream 0.1. It is okay to use on the back and chest also. She has referred to ABC Clinic for an anaesthetic consult. She would return in two month for a follow up evaluation of her acne.   Answers The patient is a 49-year-old white female, who last came to the clinic on 10/15/2021. She comes in today for a re-evaluation of her acne, plus she has had what sh

Medical Documentation Proofreading Example 7

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Proofreading She is an 79-year-old white female who present in with acute chole cystitis and underwent  attempted laparoscopic Cholecystectomy 8 day ago. The patient has required conversion for an  open procedure due to difficult anatomy. Her post operative course has been lengthened due to  a prolonged ileus, which resolved by tetracycline and Reglan. The patient is starting to improve  or gain more strength. She is tolerating his regular deit. She had an bowel movement today and  are continuing to improve. I anticipated another 3 days in the hospital for strengthening, or  cont inued TPN and resolution of eleveted White count.   Answer She is a 79-year-old white female who presented in with acute cholecystitis and underwent  attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an  open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The

Medical Documentation Proofreading Example 6

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Proofreading The patient is a unfortunate 6 month old baby boy, who have been hospitalised most of her life with recurrant chylothoraces and chylous ascitis. The patient has been treated somewhat successfuly wit TPN and voluntery restriction of enteral nutrition but he had repeated chylothoraces. Last week Dr Sam takes the patient to the Operating room in hopes that with thoracotomy a thoracic duct leak can be found, which would be successful closed surgicaly. However at the time of his thoracotomy exploration what was discovered were a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen. Dr. Sam opened the diaphragm, and could literally see a fountain of chylous fluid existing through the diaphragmatic whole. This was closed and we decided that, perhaps a abdominal exploration as a last stage effort would allow us to find a area of lymphatic leek that could potentially helped the patients. We met with her parents, and talked to them about this and

Medical Documentation Proofreading Example 5

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Proofreading The patient Katherine is 54-years-old. She come for bladder installation for chronic interstitial cystitis. The patient was crying today when she arrive in the office saying that he has a lot of discomforts. These bladder instillations do not seem to be help her. She felt anxious and worried. She do not think she can take any more pains. She is debating wether or not to go back to Dr Peter, and ask for some treatment modality to stop the pain, because she just cannot functions on a daily basis, and care for her children unless she gets something did about this, and she fears this bladder instillations because they are not seem to help. They seem to be intensifying her pain. So, she has to has somebody come with her, and that is kinds of troublesome for her. We discussed this at length. I did suggest that it was completely appropriate to her to decide. She will terminate these if they are that un comfortable, and do not seem to be giving her any relief. However I did tell h