Medical Documentation Proofreading Example 10

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.

medical transcription proofreading example


Answer

This 34-year-old gentleman woke up this morning noting some itchiness to his back and then, within a very  short period of time, realized that he had an itchy rash all over his torso and arms. He denies facial swelling or tongue or lip swelling. He has no shortness of breath, wheezing, or other associated symptoms. He  cannot think of anything that could have triggered this. There have been no changes in his food,  medications, or other exposures as far as he knows. He states a couple of days ago, while at work, he was  removing some insulation but does not remember feeling itchy that day. In the meantime, he can be managed with some antihistamine tablets. He is responding already to Benadryl and epinephrine that  we gave him here. He is told that if he develops 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.

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