Medical Documentation Proofreading Example 4

Proofreading 1

The patient is a 68 year old caucasian male with history of gross hematuria. The patient presented to the Emergency room near her hometown on 24/12/2007 for evaluation of these gross hematuria. A CT scan were performed, which demonstrates no hydronephrosis and upper tract process, however there was significant thickening of the left and posterior bladder wall. A urology referrel was initiated and the patient was send to be evaluated by Dr Samson. He eventually underwent a bladder biopsi on 01/18/08, which demonstrated high grade transitional cell carcinoma with out any muscularis propria in the speciman. Additionally the patients underwent a workup for a right adrenal lesion, which were noted on the initial CT scan. This work up involved serum cortisol analysis as well as potassium and aldosterone and ACTH level mesurement. All of these workup was found to be grossly negative. Secondery to the absence of muscle in the specimen the patient was taken aback to the operating room on 27/02/08 by Dr. Samson and the tumour was noted to be very large with significantly tumor burden as well as possible involvement of the bladder neck. At that time the referring urologist determined the tumor to be two large and risky for local re section and the patient were referred to ABCD Urology for management and diagnosis. The patient present to day for evaluation by Dr. Peter.


what is hematuria

Answers

The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. A CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. A urology referral was initiated, and the patient was sent to be evaluated by Dr. Samson. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent a workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. Samson, and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Peter.

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