Medical Documentation Proofreading Example 17

PROOFREAD

The patient is an 44-year-old white female who present today with multiple problems. The  biggest concern she has today is that her left leg had been swollen. It gets better in the  morning when she wakes up, but then through the day, it begins to swell again. The right leg  also swells, and not nearly as much as a left leg. She also complains of pain in his shoulder and  back. These starts about a year ago but the pain in her left shoulder is of most concern to her.  She feels like the low back pain are just a result of a poor matress. She does not remember  hurts her shoulder, but she said gradual she has lost some mobility. It is difficult for her to get  her hands behind her back or behind her head. She has lost strength in the left shoulder.  Regarding her blood count, she had an elevated white count. In April of 2005, Dr. Suffis had  asked Dr. Greenfield to see her because of the persistent Leukocytosis. However, Dr.  Greenfield felt that this was not a problem. He asked the patient to just return here for a  followup. She also complains of a lot at frequency with urination and nocturia. Fortunately,  her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a  prn basis. She works by the city of wichita as a bus dispacher, so she does sit a lot. I reviewed  her lab work. Other than the blood count her labwork has been pretty normal.

 

a swollen leg


ANSWER

The patient is a 44-year-old white female who presents today with multiple problems. The  biggest concern she has today is that her left leg has been swollen. It gets better in the  morning when she wakes up, but then through the day, it begins to swell again. The right leg  also swells, but not nearly as much as the left leg. She also complains of pain in his shoulder and back. These started about a year ago, but the pain in her left shoulder is of most concern to her.  She feels like the low back pain is just a result of a poor mattress. She does not remember hurting her shoulder, but she said gradually, she has lost some mobility. It is difficult for her to get  her hands behind her back or behind her head. She has lost strength in the left shoulder.  Regarding her blood count, she has an elevated white count. In April of 2005, Dr. Suffis had  asked Dr. Greenfield to see her because of the persistent leukocytosis. However, Dr.  Greenfield felt that this was not a problem. He asked the patient to just return here for followup. She also complains of a lot of frequency with urination and nocturia. Fortunately, her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a  p.r.n. basis. She works in/for the city of Wichita as a bus dispatcher, so she does sit a lot. I reviewed  her lab work. Other than the blood count, her lab work has been pretty normal.


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