Medical Documentation Proofreading Example 18

Question

The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time she was evaluated and found to have evidence at sleep disruption and day time fatigue. She also complained of nocturnal choking episodes that have since abated over the past several months. In the meantime, she had been schedule for an over night sleep study performed to evaluate her for sleep apnea. She reports difficulty by initiating sleep but then recurrent awakenings every 1 to 2 hour throughout the night. Her daughter report that she has heard the patient talking during sleep and snoring. There are no apniec episodes. Patient reports that he used to cough a lot in the middle of the night, but has no longer been doing so in recent weaks. During the daytime, the patient reports spending lot of sedentary time reading and watching tv. The patient smoke perhaps one too two packs of cigarattes per day, particular after dinner.

dyspnea

Answer

The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time, she was evaluated and found to have evidence of sleep disruption and daytime fatigue. She also complained of nocturnal choking episodes that have since abated over the past several months. In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea. She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night. Her daughter reports that she has heard the patient talking during sleep and snoring. There are no apneic episodes. The patient reports that she used to cough a lot in the middle of the night but has no longer been doing so in recent weeks. During the daytime, the patient reports spending a lot of sedentary time reading and watching TV. The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner.

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