Medical Documentation Proofreading Example 6

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 he is here to day for that attempt.

chylothorax

Chylothorax is a rare but serious condition in which lymph formed in the digestive system (chyle) accumulates in your chest cavity.


Answers

The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites. The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces. Last week, Dr. Sam took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically. However, at the time of his thoracotomy exploration, what was discovered was 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 exiting through the diaphragmatic hole. This was closed, and we decided that perhaps, an abdominal exploration as a last-stage effort would allow us to find an area of lymphatic leak that could potentially help the patient. We met with his parents and talked to them about this, and he is here today for that attempt.

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