ACCURACY: 78%
CONSULTATION REPORT
PATIENT NAME: Lisa Marie Cobb
HOSPITAL NO.: 4569870
DATE: January 14, _____
CONSULTANT: Susan C. Miller, MD
This 48-year-old female is seen at the request of Dr. Nathan Penn concerning multiple, rather vague, complaints. She was a missionary in India for quite a number of years, and while there, unfortunately, suffered the loss 1.5 INCORRECT ENGLISH MAJORof a kidney apparently from staghorn calculus. Actually the kidney was removed here but the problem developed there, and she admits that this event has led 0.5 INCORRECT ENGLISH MINORher to seek medical attention at the slightest hint of any possible abnormality, and she feels that she frequently overreacts to mild symptoms. Additionally, she feels that the stress of caring for her 93-year-old mother certainly 0.5 INCORRECT ENGLISH MINORis adding to the symptomatology 1.5 INCORRECT ENGLISH MAJORshe might be experiencing. Having begun her conversation with those 2 statements, she then related a long list of somatic complaints including substernal and epigastric burning and discomfort, a right lower quadrant pain, and a fear of colon cancer related to prior polyps removed by Dr. Teresa McCullin several years ago. She was actually admitted because of a positive treadmill study done as an outpatient followed by the onset of some epigastric and substernal discomfort. Since admission, a thallium 3.0 INCORRECT MEDICAL TERMstudy has been negative and multiple additional studies including gallbladder ultrasound, pelvic ultrasound, and ultrasound of the right kidney have been normal. I was asked my opinion concerning additional GI studies. Finally I should mention that just prior to admission, she was on nonsteroidal anti-inflammatory medication and was seen in the ER by Dr. Danny Craven several days ago who felt that some of her discomfort might have been related to esophagitis caused by the nonsteroidal which she has since discontinued.
PHYSICAL EXAMINATION
GENERAL: Physical exam 0.5 CAPITALIZATION ERRORreveals a pleasant, elderly female who is alert, cooperative, and in no distress. HEENT: Normal
NECK: Supple
CHEST: Clear
HEART: Regular rhythm without murmur that I appreciate.
ABDOMEN: Soft and nontender, has well-healed appendectomy scar noted. No organomegaly, masses or tenderness. Bowel sounds normoactive. Rectal not performed.
Available for review are her colonoscopic 3.0 INCORRECT MEDICAL TERMstudies from Our Lady of the Lake Hospital from 1995 which indicate a normal exam at this time. My opinion is that this absolutely excludes any possibility of significant colon lesion at this time, and I have counseled her that she need not concern herself with colon cancer specifically.
Actually I think that she is probably quite correct in her belief that much of this is functional and related to stress. I concur completely with the use of H2 blocker and anticholinergic in conjunction to treat both what is probably some degree of reflux coupled with functional complaints. If she fails completely to respond, then we might consider upper endoscopy, but I would certainly give her a trial of both medical therapy and hopefully some lifestyle rearrangement before considering that step.
I appreciate the consult. I see no reason to do further GI studies at this time.
Thursday, May 14, 2009
Forrest 4-15
ACCURACY:
OPERATIVE REPORT
PATIENT NAME: Herman Yougo
HOSPITAL NO.: 9256443
PHYSICIAN: Bryan Sego, MD
DATE: 0.5 COMMISSION October 25, _____
SURGEON: Byron Sego, MD
INDICATIONS
Metastatic squamous cell carcinoma to the neck, rule out lung primary.
FINDINGS
I could find nothing to suggest a bronchogenic carcinoma. There was a great deal of erythema and some swelling of the 1.5 INCORRECT ENGLISH MAJORmucosa in the right upper lobe, so this was biopsied. It does not look like gross 1.5 INCORRECT ENGLISH MAJORtumor, however.
PROCEDURE
Flexible bronchoscopy with forceps biopsy.
PREOPERATIVE MEDICATION
Atropine 3.0 INCORRECT MEDICAL TERM0.4 mg IM.
ANESTHESIA
Versed 3.0 INCORRECT MEDICAL TERM1.5 mg IV and Demerol 50 mg IV, topical lidocaine.
PROCEDURE IN DETAIL
After adequate preparation of the nose and posterior pharynx, 3.0 INCORRECT MEDICAL TERMthe fiberscope was introduced 0.5 WRONG ARTICLES/PREPOSITIONSwithout difficulty in the vocal cord area. Both cords moved 1.5 INCORRECT ENGLISH MAJORnormally with phonation and were free of lesions. The trachea and the main carina were 0.5 INCORRECT ENGLISH MINORnormal except there were some scattered thick secretions that almost stopped up the scope. 1.5 INCORRECT ENGLISH MAJOR These were finally suctioned free. 1.5 INCORRECT ENGLISH MAJOR There appeared to be some modest 1.5 INCORRECT ENGLISH MAJORblunting of the main carina. I examined both the left and the right tracheobronchial trees, and I could 0.5 INCORRECT ENGLISH MINORfind nothing specific in any airway to suggest a neoplasm. 3.0 INCORRECT MEDICAL TERM The only abnormality was in the right upper lobe where the mucosal surface 1.5 INCORRECT ENGLISH MAJORwas erythematous and the carina of the upper lobe somewhat blunted. I biopsied several areas here and also took bronchial washings from the area. There were no other suspicious areas, and no other bronchial washings were collected. The patient tolerated the procedure well and had the Versed reversed with Romazicon 3.0 INCORRECT MEDICAL TERMprior to transfer to his room.
OPERATIVE REPORT
PATIENT NAME: Herman Yougo
HOSPITAL NO.: 9256443
PHYSICIAN: Bryan Sego, MD
DATE: 0.5 COMMISSION October 25, _____
SURGEON: Byron Sego, MD
INDICATIONS
Metastatic squamous cell carcinoma to the neck, rule out lung primary.
FINDINGS
I could find nothing to suggest a bronchogenic carcinoma. There was a great deal of erythema and some swelling of the 1.5 INCORRECT ENGLISH MAJORmucosa in the right upper lobe, so this was biopsied. It does not look like gross 1.5 INCORRECT ENGLISH MAJORtumor, however.
PROCEDURE
Flexible bronchoscopy with forceps biopsy.
PREOPERATIVE MEDICATION
Atropine 3.0 INCORRECT MEDICAL TERM0.4 mg IM.
ANESTHESIA
Versed 3.0 INCORRECT MEDICAL TERM1.5 mg IV and Demerol 50 mg IV, topical lidocaine.
PROCEDURE IN DETAIL
After adequate preparation of the nose and posterior pharynx, 3.0 INCORRECT MEDICAL TERMthe fiberscope was introduced 0.5 WRONG ARTICLES/PREPOSITIONSwithout difficulty in the vocal cord area. Both cords moved 1.5 INCORRECT ENGLISH MAJORnormally with phonation and were free of lesions. The trachea and the main carina were 0.5 INCORRECT ENGLISH MINORnormal except there were some scattered thick secretions that almost stopped up the scope. 1.5 INCORRECT ENGLISH MAJOR These were finally suctioned free. 1.5 INCORRECT ENGLISH MAJOR There appeared to be some modest 1.5 INCORRECT ENGLISH MAJORblunting of the main carina. I examined both the left and the right tracheobronchial trees, and I could 0.5 INCORRECT ENGLISH MINORfind nothing specific in any airway to suggest a neoplasm. 3.0 INCORRECT MEDICAL TERM The only abnormality was in the right upper lobe where the mucosal surface 1.5 INCORRECT ENGLISH MAJORwas erythematous and the carina of the upper lobe somewhat blunted. I biopsied several areas here and also took bronchial washings from the area. There were no other suspicious areas, and no other bronchial washings were collected. The patient tolerated the procedure well and had the Versed reversed with Romazicon 3.0 INCORRECT MEDICAL TERMprior to transfer to his room.
Forrest 5-13
ex5_ch13
LOD = 2:28
OPERATIVE REPORT
OPERATION
PATIENT: Eileen NAME: Elaine Halloway
HOSPITAL NO.: 5689997-4
DATE: May 20, _____
SURGEON: John HendrickHendrix, MD
PREOPERATIVE DIAGNOSIS
Incomplete spontaneous abortion.
POSTOPERATIVE DIAGNOSIS
Incomplete spontaneous abortion.
PROCEDURE
Suction curettage.
ANESTHESIA
Intravenous IV sedation phenol [minus 3.0 for INCORRECT MEDICINE NAME] (fentanyl and valiumValium) [minus 1.5 for CASING OF MEDICATIONS] and paracervical block (1% Xylocaine).
ESTIMATED BLOOD LOSS
Estimated blood loss less then [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] Less than 5 cc.
COMPLICATIONS
None.
FINDINGS
Uterine cavity sounded to a depth of 8 cm., scant tissues tissue obtained on curettage.
PROCEDURE IN DETAILS
After proper consentconsents were obtained, the patient was taken to the operating room and placed on the table in a the supine position. She was then placed in a stirrupstirrups in the modified dorsal lithotomy dorsolithotomy position. The patientpatient’s [minus 0.5 for GRAMMAR ERROR] perineum and vagina were in then [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] prepped and draped in the usual sterile fashion. She was then given IV sedation consisting of Phenolfentanyl 2 cc given slow IV push and valiumValium 10 mg given slow IV push. A graveGraves [minus 0.5 for CAPITALIZATION ERROR] speculum was then inserted into the vagina and opened a. A [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] paracervical block was then given at the 3 o’clock and 9 o’clock position positions proximal to the cervix with a 5 mm mL [minus 1.5 for INCORRECT ENGLISH WORD] of 1% Xylocaine infiltrated on each side. The anterior lymphlip [minus 1.5 for INCORRECT ENGLISH WORD] of the cervix was then grasped with a single toothed single-tooth tenaculum and retraction applied. The uterine cavity was then sounded to a depth of 8 cm the . The [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] internal cervical os was then dilated up to a 17 hankHank [minus 0.5 for CAPITALIZATION ERROR] dilator. The uterine cavity was then evacuated with suction curettage using a 7 -mm suction catheter tip with the a small amount of tissue being obtained and sent for pathology, this. This was followed by sharp curettage. The uterine cavity was then resounded to a depth of 8 cm. The procedure was then terminated. The tenaculum was removed from the patientpatient’s cervix and the. The speculum was removed from the patientpatient’s vagina. She was taken out of the lithotomy postion position [minus 0.5 for TYPO / SPELLING ERROR] and placed back in the supine position. She was awakened at in the operating room in a stable condition. There were no intraoperative complications.
line count = 29.80
negative pts. = 11.50 (38%)
ACCURACY = 62%
LOD = 2:28
OPERATIVE REPORT
OPERATION
PATIENT: Eileen NAME: Elaine Halloway
HOSPITAL NO.: 5689997-4
DATE: May 20, _____
SURGEON: John HendrickHendrix, MD
PREOPERATIVE DIAGNOSIS
Incomplete spontaneous abortion.
POSTOPERATIVE DIAGNOSIS
Incomplete spontaneous abortion.
PROCEDURE
Suction curettage.
ANESTHESIA
Intravenous IV sedation phenol [minus 3.0 for INCORRECT MEDICINE NAME] (fentanyl and valiumValium) [minus 1.5 for CASING OF MEDICATIONS] and paracervical block (1% Xylocaine).
ESTIMATED BLOOD LOSS
Estimated blood loss less then [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] Less than 5 cc.
COMPLICATIONS
None.
FINDINGS
Uterine cavity sounded to a depth of 8 cm., scant tissues tissue obtained on curettage.
PROCEDURE IN DETAILS
After proper consentconsents were obtained, the patient was taken to the operating room and placed on the table in a the supine position. She was then placed in a stirrupstirrups in the modified dorsal lithotomy dorsolithotomy position. The patientpatient’s [minus 0.5 for GRAMMAR ERROR] perineum and vagina were in then [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] prepped and draped in the usual sterile fashion. She was then given IV sedation consisting of Phenolfentanyl 2 cc given slow IV push and valiumValium 10 mg given slow IV push. A graveGraves [minus 0.5 for CAPITALIZATION ERROR] speculum was then inserted into the vagina and opened a. A [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] paracervical block was then given at the 3 o’clock and 9 o’clock position positions proximal to the cervix with a 5 mm mL [minus 1.5 for INCORRECT ENGLISH WORD] of 1% Xylocaine infiltrated on each side. The anterior lymphlip [minus 1.5 for INCORRECT ENGLISH WORD] of the cervix was then grasped with a single toothed single-tooth tenaculum and retraction applied. The uterine cavity was then sounded to a depth of 8 cm the . The [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] internal cervical os was then dilated up to a 17 hankHank [minus 0.5 for CAPITALIZATION ERROR] dilator. The uterine cavity was then evacuated with suction curettage using a 7 -mm suction catheter tip with the a small amount of tissue being obtained and sent for pathology, this. This was followed by sharp curettage. The uterine cavity was then resounded to a depth of 8 cm. The procedure was then terminated. The tenaculum was removed from the patientpatient’s cervix and the. The speculum was removed from the patientpatient’s vagina. She was taken out of the lithotomy postion position [minus 0.5 for TYPO / SPELLING ERROR] and placed back in the supine position. She was awakened at in the operating room in a stable condition. There were no intraoperative complications.
line count = 29.80
negative pts. = 11.50 (38%)
ACCURACY = 62%
Forrest 2-10
ex2_ch10
LOD = 2:08
OPERATIVE REPORT
OPERATION
PATIENT NAME: Jenel BordelanJeanelle Bordelon
HOSPITAL NO.: 5049247
DATE OF PROCEDURE: May 15, _____
SURGEON: John C. Howard, MD
ANESTHESIOLOGIST: Sean Swellow, MD
ANESTHESIA
General Endotracheal.
PREOPERATIVE DIAGNOSIS
Bilateral subdural hematomas.
POST OPERATIVE POSTOPERATIVE DIAGNOSIS
Bilateral subdural hematomas.
PROCEDURES: PROCEDURE
Bilateral burr bur holes, frontal and parietal, for drainage of subdural hematomas.
SURGEON: John C. Howard, MD
ANESTHESIOLOGIST: Sean Suelo, MD
ANESTHESIA
General endotracheal.
PROCEDURE IN DETAIL
The patient was brought into the operating room, and after induction of general endotracheal anesthesia. The , the [minus 0.5 for PUNCTUATION ERROR] head was completely shaved, and prepped and draped in the usual manner. An incision was made over the frontal areas approximately 3.0 cm from the midline on both sides. The incision was The incisions were carried down through the scalp, rainy scalp. Raney [minus ___ for INCORRECT MEDICAL/SURGICAL EQPT NAME] clips were applied for hemostasis, self retaining retractor hemostasis. Self-retaining retractors were placed, burr placed. Bur [minus 0.5 for PUNCTUATION ERROR] holes hashave been made with a common perforator. Bleeding from bone was then controlled with bone wax. The left flexed The last flecks [minus 1.5 for INCORRECT ENGLISH WORD/s] of bone were taken out with a curette and the dura underneath was coagulated in a cruciate fashion. The dura was openopened [minus 0.5 for WRONG TENSE OF VERB] widely and copious amountamounts of old crankcase -colored blood should form. issued forth. [minus 1.5 for INCORRECT ENGLISH WORD] This was irrigated copiously on both side sides, and blakethe Blake 7 -mm [minus 0.5 for CAPITALIZATION ERROR] drain were advancedrains were advanced [minus 0.5 for WRONG TENSE OF VERB] under the scalp and into thisthese [minus 0.5 for GRAMMAR ERROR] holes and to this into the [minus 0.5 for WRONG PREPOSITION] subdural space. Both wounds were close closed [minus 0.5 for WRONG TENSE OF VERB] then with zero vicryl who0 Vicryl to [minus 0.5 for CAPITALIZATION ERROR] close the galeo galea [minus 3.0 for INCORRECT MEDICAL TERM] layer and 3.-0 nylon to close the skin. Xeroform dressingdressings were applied and both drain. Both drains were secured with 2.-0 silks. The patient was recovered from anesthesia and taken to the recovery room in satisfactory condition.
line count = 23.56
negative pts. = 10.50 (44%)
ACCURACY = 56%
LOD = 2:08
OPERATIVE REPORT
OPERATION
PATIENT NAME: Jenel BordelanJeanelle Bordelon
HOSPITAL NO.: 5049247
DATE OF PROCEDURE: May 15, _____
SURGEON: John C. Howard, MD
ANESTHESIOLOGIST: Sean Swellow, MD
ANESTHESIA
General Endotracheal.
PREOPERATIVE DIAGNOSIS
Bilateral subdural hematomas.
POST OPERATIVE POSTOPERATIVE DIAGNOSIS
Bilateral subdural hematomas.
PROCEDURES: PROCEDURE
Bilateral burr bur holes, frontal and parietal, for drainage of subdural hematomas.
SURGEON: John C. Howard, MD
ANESTHESIOLOGIST: Sean Suelo, MD
ANESTHESIA
General endotracheal.
PROCEDURE IN DETAIL
The patient was brought into the operating room, and after induction of general endotracheal anesthesia. The , the [minus 0.5 for PUNCTUATION ERROR] head was completely shaved, and prepped and draped in the usual manner. An incision was made over the frontal areas approximately 3.0 cm from the midline on both sides. The incision was The incisions were carried down through the scalp, rainy scalp. Raney [minus ___ for INCORRECT MEDICAL/SURGICAL EQPT NAME] clips were applied for hemostasis, self retaining retractor hemostasis. Self-retaining retractors were placed, burr placed. Bur [minus 0.5 for PUNCTUATION ERROR] holes hashave been made with a common perforator. Bleeding from bone was then controlled with bone wax. The left flexed The last flecks [minus 1.5 for INCORRECT ENGLISH WORD/s] of bone were taken out with a curette and the dura underneath was coagulated in a cruciate fashion. The dura was openopened [minus 0.5 for WRONG TENSE OF VERB] widely and copious amountamounts of old crankcase -colored blood should form. issued forth. [minus 1.5 for INCORRECT ENGLISH WORD] This was irrigated copiously on both side sides, and blakethe Blake 7 -mm [minus 0.5 for CAPITALIZATION ERROR] drain were advancedrains were advanced [minus 0.5 for WRONG TENSE OF VERB] under the scalp and into thisthese [minus 0.5 for GRAMMAR ERROR] holes and to this into the [minus 0.5 for WRONG PREPOSITION] subdural space. Both wounds were close closed [minus 0.5 for WRONG TENSE OF VERB] then with zero vicryl who0 Vicryl to [minus 0.5 for CAPITALIZATION ERROR] close the galeo galea [minus 3.0 for INCORRECT MEDICAL TERM] layer and 3.-0 nylon to close the skin. Xeroform dressingdressings were applied and both drain. Both drains were secured with 2.-0 silks. The patient was recovered from anesthesia and taken to the recovery room in satisfactory condition.
line count = 23.56
negative pts. = 10.50 (44%)
ACCURACY = 56%
Forrest 10-14
ex10_ch14 (ethnic voice)
LOD = 2:14
DISCHARGE SUMMARY
PATIENT NAME: Jennifer Bakutis
HOSPITAL NO.: 9682967
DATE: December 19, _____
ADMISSION DIAGNOSIS
Pneumonia.
HISTORY OF PRESENT ILLNESS
A 7-year-old white female with partial trisomy 13 followed at the University medical center for chronic rewind [minus 1.5 for INCORRECT ENGLISH WORD] pneumonia.
ETIOLOGY
Unknown.
She was seen by Dr. Scott Miller for this [minus 1.5 for INCORRECT ENGLISH WORD/s] prior to admission and began on augmentin. [minus 1.5 for CASING OF MEDICATIONS] She had fever then and continued to have fever and was seen at the emergency room at the hospital on the night of admission showing a right middle and lower lobe infiltrate. She was admitted for further IV treatment.
HISTORY OF PRESENT ILLNESS
A 7-year-old white female with partial trisomy 13, followed at University Medical Center for chronic recurrent pneumonia, etiology unknown. She was seen by Dr. Scott Miller 4 days prior to admission and begun on Augmentin. She had fever then and continued to have fever, and was seen in the emergency room at the hospital on the night of admission, showing a right middle and lower lobe infiltrate. She was admitted for further IV treatment.
PHYSICAL EXAMINATION
Within a [minus 0.5 for ADDING WORDS NOT DICTATED] normal limits, except for ronchi andrhonchi in [minus 3.0 for INCORRECT SPELLING MEDICAL TERM] the chest. The child has no verbal communication and forpoor [minus 1.5 for INCORRECT ENGLISH WORD] socialization.
ADMISSION LABORATORY
On admission hemoglobin was 12.3, hematocrit 36.0, white count 12300, [minus 0.5 for STYLES ERROR] with 54 segs, 37 lymphs, 3 monos, 5 eos, and 1 basos. [minus 0.5 for GRAMMAR ERROR] Chem 6 was within normal limits except for a blood sugar of 141.
URINALYSIS
Within normal limits. Mycoplasma and RSV were negative. Throat culture shows normal flora.
ADMISSION LABORATORY
On admission hemoglobin was 12.3, hematocrit 36.0, white count 12,300, with 54 segs, 37 lymphs, 3 monos, 5 eos, and 1 baso. Chem 6 was within normal limits except for a blood sugar of 141. Routine urinalysis, within normal limits. Mycoplasma and RSV were negative. Throat culture shows normal flora.
HOSPITAL COURSE
She was started on a claforan 300Claforan 300 [minus 1.5 for CASING OF MEDICATIONS] mg IV q.6h q.6 h. and nebulized albuterol q.4h. q.4 h. Temperature was normal during the entire stay. While being treated, the child chests child’s chest [minus 0.5 for GRAMMAR ERROR] finding slowly improved, and the lungs were clear to auscultation on the night of October 16. October 16, _____.
At that time, she was placed on sip cell.Cefzil. [minus 3.0 for INCORRECT MEDICINE NAME] The claforanClaforan was stopped on. On [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] the morning of discharge, chest x-ray showed the right middle lobe clear and the right lower lobe showing minimal residual infiltrate. Lung was cleared Lungs were clear [minus 0.5 for GRAMMAR ERROR] to auscultation.
DISPOSITION
Discharged. Discharge.
DISCHARGED MEDICATION
Sip cell 250
DISCHARGE MEDICATIONS
Cefzil 250 mg b.i.d.., Ventolin by aerosol 2 to 3 times a day.
FOLLOW UP
Appointment in one 1 week.
line count = 25.76
negative pts. = 16.50 (64%)
ACCURACY = 36%
LOD = 2:14
DISCHARGE SUMMARY
PATIENT NAME: Jennifer Bakutis
HOSPITAL NO.: 9682967
DATE: December 19, _____
ADMISSION DIAGNOSIS
Pneumonia.
HISTORY OF PRESENT ILLNESS
A 7-year-old white female with partial trisomy 13 followed at the University medical center for chronic rewind [minus 1.5 for INCORRECT ENGLISH WORD] pneumonia.
ETIOLOGY
Unknown.
She was seen by Dr. Scott Miller for this [minus 1.5 for INCORRECT ENGLISH WORD/s] prior to admission and began on augmentin. [minus 1.5 for CASING OF MEDICATIONS] She had fever then and continued to have fever and was seen at the emergency room at the hospital on the night of admission showing a right middle and lower lobe infiltrate. She was admitted for further IV treatment.
HISTORY OF PRESENT ILLNESS
A 7-year-old white female with partial trisomy 13, followed at University Medical Center for chronic recurrent pneumonia, etiology unknown. She was seen by Dr. Scott Miller 4 days prior to admission and begun on Augmentin. She had fever then and continued to have fever, and was seen in the emergency room at the hospital on the night of admission, showing a right middle and lower lobe infiltrate. She was admitted for further IV treatment.
PHYSICAL EXAMINATION
Within a [minus 0.5 for ADDING WORDS NOT DICTATED] normal limits, except for ronchi andrhonchi in [minus 3.0 for INCORRECT SPELLING MEDICAL TERM] the chest. The child has no verbal communication and forpoor [minus 1.5 for INCORRECT ENGLISH WORD] socialization.
ADMISSION LABORATORY
On admission hemoglobin was 12.3, hematocrit 36.0, white count 12300, [minus 0.5 for STYLES ERROR] with 54 segs, 37 lymphs, 3 monos, 5 eos, and 1 basos. [minus 0.5 for GRAMMAR ERROR] Chem 6 was within normal limits except for a blood sugar of 141.
URINALYSIS
Within normal limits. Mycoplasma and RSV were negative. Throat culture shows normal flora.
ADMISSION LABORATORY
On admission hemoglobin was 12.3, hematocrit 36.0, white count 12,300, with 54 segs, 37 lymphs, 3 monos, 5 eos, and 1 baso. Chem 6 was within normal limits except for a blood sugar of 141. Routine urinalysis, within normal limits. Mycoplasma and RSV were negative. Throat culture shows normal flora.
HOSPITAL COURSE
She was started on a claforan 300Claforan 300 [minus 1.5 for CASING OF MEDICATIONS] mg IV q.6h q.6 h. and nebulized albuterol q.4h. q.4 h. Temperature was normal during the entire stay. While being treated, the child chests child’s chest [minus 0.5 for GRAMMAR ERROR] finding slowly improved, and the lungs were clear to auscultation on the night of October 16. October 16, _____.
At that time, she was placed on sip cell.Cefzil. [minus 3.0 for INCORRECT MEDICINE NAME] The claforanClaforan was stopped on. On [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] the morning of discharge, chest x-ray showed the right middle lobe clear and the right lower lobe showing minimal residual infiltrate. Lung was cleared Lungs were clear [minus 0.5 for GRAMMAR ERROR] to auscultation.
DISPOSITION
Discharged. Discharge.
DISCHARGED MEDICATION
Sip cell 250
DISCHARGE MEDICATIONS
Cefzil 250 mg b.i.d.., Ventolin by aerosol 2 to 3 times a day.
FOLLOW UP
Appointment in one 1 week.
line count = 25.76
negative pts. = 16.50 (64%)
ACCURACY = 36%
Forrest 9-14
ex9_ch14
LOD = 2:12
HISTORY AND PHYSICAL EXAMINATION
PATIENT NAME: Baby Taylor
HOSPITAL NO.: 4465578
DATE OF ADMISSION: January 5, _____
HOSPITAL COURSE
The patient was a 1.3-year-old 5 1.305-kg [minus 1.5 for INCORRECT ENGLISH WORD] product of a 27 weeks 27-week gestation to a G1, 15-year-old black female. Pregnancy complicated by preeclampsia and gonorrhea, treated on August 5, 1996. The mother is Rh positive, serology negative, rubella titer reactive, hepatitis surface antigen negative,. HIV negative. The patient was delivered secondary to pre-term labor and increased blood pressure. C-section was performed the. The [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] patient delivered without spontaneous respiration. The patient was intubated with 3.0 ET tube, and Survanta 5.2 cc were given forper [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] protocol. The patient was transferred to NICU, and UAC and UVC were placed without difficulty. Apgar Apgars were 11 and 9 at one and five minutes, respectively.
PHYSICAL EXAMINATION
WEIGHT: 1.305 kg.
LENGTH: 38 cm.
HEAD CIRCUMFERENCE: 27.5 cm.
Weight 1.305 kg, length 38 cm, head circumference 27.5 cm.
VITAL SIGNS: Temperature 97.4, pulse 144, respiratory respiration [minus 0.5 for MINOR ERROR] 40.
GENERAL: Well -developed black male, proximately approximately [minus 1.5 for INCORRECT ENGLISH WORD] 27 weeks weeks’ gestation.
HEENT: Normocephalic. [minus 0.5 for PUNCTUATION ERROR] Anterior fontanel Normocephalic, anterior fontanelle is flat and soft. Eyes are open, ears open. Ears are normal. Oral pharynx Oropharynx [minus 1.5 for MISSPELLED MEDTERM] benign.
NECK: Supple without masses.
HEART: Regular rate and rhythm without murmurs, murmur, rub, or galloped. gallop. [minus 1.5 for INCORRECT ENGLISH WORD/s]
LUNGS: Mild subcostal retractions, mild intercostals retraction, rales intercostal retractions. Rales [minus 0.5 for MINOR ERROR] bilaterally, breath sound bilaterally. Breath sounds equal bilaterally.
ABDOMEN: Soft and non tender, positive nontender. Positive bowel sound, GU normal sounds.
GENITOURINARY: Normal male genitalia, no cc or pee. [minus 1.5 for INCORRECT ENGLISH WORD]
EXTREMITIES: No clubbing, cyanosis, or edema.
IMPRESSIONS
IMPRESSION
1. Pre-term birth, living child approximately 29 weeks weeks’ gestation.
2. Hyaline membrane disease.
3. Ruled- Rule out sepsis.
4. Mother pre-treated with steroids and antibiotics.
PLAN
1. Admit to an NICU, [minus 0.5 for MINOR ERROR] IV fluids and antibiotics.
2. Enzai MV SIMV [minus 1.5 for INCORRECT MEDICAL / ENGLISH ABBREVIATIONS] and survanta Survanta. [minus 1.5 for CASING OF MEDICATIONS]
3. Indomethacin.
line count = 26.30
negative pts. = 13.50 (51%)
ACCURACY = 49%
LOD = 2:12
HISTORY AND PHYSICAL EXAMINATION
PATIENT NAME: Baby Taylor
HOSPITAL NO.: 4465578
DATE OF ADMISSION: January 5, _____
HOSPITAL COURSE
The patient was a 1.3-year-old 5 1.305-kg [minus 1.5 for INCORRECT ENGLISH WORD] product of a 27 weeks 27-week gestation to a G1, 15-year-old black female. Pregnancy complicated by preeclampsia and gonorrhea, treated on August 5, 1996. The mother is Rh positive, serology negative, rubella titer reactive, hepatitis surface antigen negative,. HIV negative. The patient was delivered secondary to pre-term labor and increased blood pressure. C-section was performed the. The [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] patient delivered without spontaneous respiration. The patient was intubated with 3.0 ET tube, and Survanta 5.2 cc were given forper [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] protocol. The patient was transferred to NICU, and UAC and UVC were placed without difficulty. Apgar Apgars were 11 and 9 at one and five minutes, respectively.
PHYSICAL EXAMINATION
WEIGHT: 1.305 kg.
LENGTH: 38 cm.
HEAD CIRCUMFERENCE: 27.5 cm.
Weight 1.305 kg, length 38 cm, head circumference 27.5 cm.
VITAL SIGNS: Temperature 97.4, pulse 144, respiratory respiration [minus 0.5 for MINOR ERROR] 40.
GENERAL: Well -developed black male, proximately approximately [minus 1.5 for INCORRECT ENGLISH WORD] 27 weeks weeks’ gestation.
HEENT: Normocephalic. [minus 0.5 for PUNCTUATION ERROR] Anterior fontanel Normocephalic, anterior fontanelle is flat and soft. Eyes are open, ears open. Ears are normal. Oral pharynx Oropharynx [minus 1.5 for MISSPELLED MEDTERM] benign.
NECK: Supple without masses.
HEART: Regular rate and rhythm without murmurs, murmur, rub, or galloped. gallop. [minus 1.5 for INCORRECT ENGLISH WORD/s]
LUNGS: Mild subcostal retractions, mild intercostals retraction, rales intercostal retractions. Rales [minus 0.5 for MINOR ERROR] bilaterally, breath sound bilaterally. Breath sounds equal bilaterally.
ABDOMEN: Soft and non tender, positive nontender. Positive bowel sound, GU normal sounds.
GENITOURINARY: Normal male genitalia, no cc or pee. [minus 1.5 for INCORRECT ENGLISH WORD]
EXTREMITIES: No clubbing, cyanosis, or edema.
IMPRESSIONS
IMPRESSION
1. Pre-term birth, living child approximately 29 weeks weeks’ gestation.
2. Hyaline membrane disease.
3. Ruled- Rule out sepsis.
4. Mother pre-treated with steroids and antibiotics.
PLAN
1. Admit to an NICU, [minus 0.5 for MINOR ERROR] IV fluids and antibiotics.
2. Enzai MV SIMV [minus 1.5 for INCORRECT MEDICAL / ENGLISH ABBREVIATIONS] and survanta Survanta. [minus 1.5 for CASING OF MEDICATIONS]
3. Indomethacin.
line count = 26.30
negative pts. = 13.50 (51%)
ACCURACY = 49%
Geneto 2
BMT RED - GENITOURINARY #2
LOD = 0:44
PREOPERATIVE NOTE
A patientPatient is a 65-year-old white male, status post- radical prostatectomy for cancer on carcinoma of the prostate, who during that same year underwent implantation of an inflatable penile prosthesis for [minus 0.5 for OMITTED a DICTATED WORD] organic infinite impotence [minus 1.5 for INCORRECT ENGLISH WORD] secondary to the radical prostatectomy. The prosthesis has been malfunctioning for a number of years and is causing the patient a pain in the right scrotum, and on exam, the pump device seems to have eroded into the right testicle, as they are indistinguishable from one another on exam. The patient another. Patient now present [minus 0.5 for GRAMMAR ERROR] presents for removal of the malfunctioning penile prosthesis and insertion of a new inflatable penile prosthesis.
line count = 9.63
negative pts. = 2.50 (25%)
ACCURACY = 75%
LOD = 0:44
PREOPERATIVE NOTE
A patientPatient is a 65-year-old white male, status post- radical prostatectomy for cancer on carcinoma of the prostate, who during that same year underwent implantation of an inflatable penile prosthesis for [minus 0.5 for OMITTED a DICTATED WORD] organic infinite impotence [minus 1.5 for INCORRECT ENGLISH WORD] secondary to the radical prostatectomy. The prosthesis has been malfunctioning for a number of years and is causing the patient a pain in the right scrotum, and on exam, the pump device seems to have eroded into the right testicle, as they are indistinguishable from one another on exam. The patient another. Patient now present [minus 0.5 for GRAMMAR ERROR] presents for removal of the malfunctioning penile prosthesis and insertion of a new inflatable penile prosthesis.
line count = 9.63
negative pts. = 2.50 (25%)
ACCURACY = 75%
ob 8
BMT GRAY – OB-GYN #15
LOD = 1:59
HISTORY AND PHYSICAL EXAMINATION
DIAGNOSIS: Incomplete abortion.
SUMMARY: This patient is a 16-year-old G1P0 gravida 1, para 0, menarche at aged age 13, whose last menstrual period was March 11 to have a , who had a [minus 1.5 for INCORRECT ENGLISH WORD/s] positive beta HCGhCG; [minus 0.5 for CAPITALIZATION ERROR] previous to that, normal menstrual cyclecycles every 28 days. She saidsays [minus 0.5 for WRONG TENSE OF VERB] that she has never had a Pap smear. She was originally seen 2 days ago regarding vaginal bleeding and thought that she had passpassed [minus 0.5 for WRONG TENSE] some tissue. She felt that she probably had spontaneously abortiveaborted [minus 1.5 for INCORRECT ENGLISH WORD] completely. She was told to come to the office in the event of any increaseincreased [minus 0.5 for GRAMMAR ERROR] vaginal bleeding. The bleeding temporized yesterday, but it then became heavy today with a lot of uterine cramps and passing of large clots since and [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] some further tissue -like material in herper vagina. She did not save any of this material for cross us [minus 1.5 for INCORRECT ENGLISH WORD] for examination.
At the time of the office visit today, she was bleeding more than would be usual for her period, with crampy abdominal pain, and the cervical os was opened open and blood clot clots [minus 0.5 for GRAMMAR ERROR] were seemsseen [minus 1.5 for INCORRECT ENGLISH WORD] protruding from the os.
PHYSICAL EXAMINATION
GENERAL: : She is alert and oriented timesx 3 and , in [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] no acute distress.
VITAL SIGNS: Blood pressure 100/66, respirationrespirations 16, pulse 76, temperature 98.6.
PEVIC EXAMINATIONS: Reveals Pelvic examination reveals essentially healthy vagina with blood involved in the vault and [minus 1.5 for INCORRECT ENGLISH WORD] cervical os. The uterus is anteverted, 6 weeks sized and noble. weeks’ size, and mobile. [minus 1.5 for INCORRECT ENGLISH WORD/s] Adnexa are grossly normal. No palpable masses. Rectal examination was negative.
RECTAL EXAMINATIONS: Negative.
I sendsent [minus 0.5 for WRONG TENSE OF VERB] her forfor a sonogram to confirm an incomplete ABabortion, which was confirmed.
PLAN
We: Will [minus 1.5 for INCORRECT ENGLISH WORD] proceed with suctioned suction [minus 0.5 for MINOR ERROR] curettage under general anesthesia. She has been NPO n.p.o. [minus 0.5 for CAPITALIZATION ERROR] since 1:00, and pre operative blood work has been sent, including CBC, Pt, Ptt PT, PTT, [minus 0.5 for CAPITALIZATION ERROR] and urinalysis. She would will be [minus 0.5 for GRAMMAR ERROR] done under outpatient surgery.
line count = 25.49
negative pts. = 16.50 (64%)
ACCURACY = 36%
LOD = 1:59
HISTORY AND PHYSICAL EXAMINATION
DIAGNOSIS: Incomplete abortion.
SUMMARY: This patient is a 16-year-old G1P0 gravida 1, para 0, menarche at aged age 13, whose last menstrual period was March 11 to have a , who had a [minus 1.5 for INCORRECT ENGLISH WORD/s] positive beta HCGhCG; [minus 0.5 for CAPITALIZATION ERROR] previous to that, normal menstrual cyclecycles every 28 days. She saidsays [minus 0.5 for WRONG TENSE OF VERB] that she has never had a Pap smear. She was originally seen 2 days ago regarding vaginal bleeding and thought that she had passpassed [minus 0.5 for WRONG TENSE] some tissue. She felt that she probably had spontaneously abortiveaborted [minus 1.5 for INCORRECT ENGLISH WORD] completely. She was told to come to the office in the event of any increaseincreased [minus 0.5 for GRAMMAR ERROR] vaginal bleeding. The bleeding temporized yesterday, but it then became heavy today with a lot of uterine cramps and passing of large clots since and [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] some further tissue -like material in herper vagina. She did not save any of this material for cross us [minus 1.5 for INCORRECT ENGLISH WORD] for examination.
At the time of the office visit today, she was bleeding more than would be usual for her period, with crampy abdominal pain, and the cervical os was opened open and blood clot clots [minus 0.5 for GRAMMAR ERROR] were seemsseen [minus 1.5 for INCORRECT ENGLISH WORD] protruding from the os.
PHYSICAL EXAMINATION
GENERAL: : She is alert and oriented timesx 3 and , in [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] no acute distress.
VITAL SIGNS: Blood pressure 100/66, respirationrespirations 16, pulse 76, temperature 98.6.
PEVIC EXAMINATIONS: Reveals Pelvic examination reveals essentially healthy vagina with blood involved in the vault and [minus 1.5 for INCORRECT ENGLISH WORD] cervical os. The uterus is anteverted, 6 weeks sized and noble. weeks’ size, and mobile. [minus 1.5 for INCORRECT ENGLISH WORD/s] Adnexa are grossly normal. No palpable masses. Rectal examination was negative.
RECTAL EXAMINATIONS: Negative.
I sendsent [minus 0.5 for WRONG TENSE OF VERB] her forfor a sonogram to confirm an incomplete ABabortion, which was confirmed.
PLAN
We: Will [minus 1.5 for INCORRECT ENGLISH WORD] proceed with suctioned suction [minus 0.5 for MINOR ERROR] curettage under general anesthesia. She has been NPO n.p.o. [minus 0.5 for CAPITALIZATION ERROR] since 1:00, and pre operative blood work has been sent, including CBC, Pt, Ptt PT, PTT, [minus 0.5 for CAPITALIZATION ERROR] and urinalysis. She would will be [minus 0.5 for GRAMMAR ERROR] done under outpatient surgery.
line count = 25.49
negative pts. = 16.50 (64%)
ACCURACY = 36%
ob 15
BMT GRAY – OB-GYN #15
LOD = 1:59
HISTORY AND PHYSICAL EXAMINATION
DIAGNOSIS: Incomplete abortion.
SUMMARY: This patient is a 16-year-old G1P0 gravida 1, para 0, menarche at aged age 13, whose last menstrual period was March 11 to have a , who had a [minus 1.5 for INCORRECT ENGLISH WORD/s] positive beta HCGhCG; [minus 0.5 for CAPITALIZATION ERROR] previous to that, normal menstrual cyclecycles every 28 days. She saidsays [minus 0.5 for WRONG TENSE OF VERB] that she has never had a Pap smear. She was originally seen 2 days ago regarding vaginal bleeding and thought that she had passpassed [minus 0.5 for WRONG TENSE] some tissue. She felt that she probably had spontaneously abortiveaborted [minus 1.5 for INCORRECT ENGLISH WORD] completely. She was told to come to the office in the event of any increaseincreased [minus 0.5 for GRAMMAR ERROR] vaginal bleeding. The bleeding temporized yesterday, but it then became heavy today with a lot of uterine cramps and passing of large clots since and [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] some further tissue -like material in herper vagina. She did not save any of this material for cross us [minus 1.5 for INCORRECT ENGLISH WORD] for examination.
At the time of the office visit today, she was bleeding more than would be usual for her period, with crampy abdominal pain, and the cervical os was opened open and blood clot clots [minus 0.5 for GRAMMAR ERROR] were seemsseen [minus 1.5 for INCORRECT ENGLISH WORD] protruding from the os.
PHYSICAL EXAMINATION
GENERAL: : She is alert and oriented timesx 3 and , in [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] no acute distress.
VITAL SIGNS: Blood pressure 100/66, respirationrespirations 16, pulse 76, temperature 98.6.
PEVIC EXAMINATIONS: Reveals Pelvic examination reveals essentially healthy vagina with blood involved in the vault and [minus 1.5 for INCORRECT ENGLISH WORD] cervical os. The uterus is anteverted, 6 weeks sized and noble. weeks’ size, and mobile. [minus 1.5 for INCORRECT ENGLISH WORD/s] Adnexa are grossly normal. No palpable masses. Rectal examination was negative.
RECTAL EXAMINATIONS: Negative.
I sendsent [minus 0.5 for WRONG TENSE OF VERB] her forfor a sonogram to confirm an incomplete ABabortion, which was confirmed.
PLAN
We: Will [minus 1.5 for INCORRECT ENGLISH WORD] proceed with suctioned suction [minus 0.5 for MINOR ERROR] curettage under general anesthesia. She has been NPO n.p.o. [minus 0.5 for CAPITALIZATION ERROR] since 1:00, and pre operative blood work has been sent, including CBC, Pt, Ptt PT, PTT, [minus 0.5 for CAPITALIZATION ERROR] and urinalysis. She would will be [minus 0.5 for GRAMMAR ERROR] done under outpatient surgery.
line count = 25.49
negative pts. = 16.50 (64%)
ACCURACY = 36%
LOD = 1:59
HISTORY AND PHYSICAL EXAMINATION
DIAGNOSIS: Incomplete abortion.
SUMMARY: This patient is a 16-year-old G1P0 gravida 1, para 0, menarche at aged age 13, whose last menstrual period was March 11 to have a , who had a [minus 1.5 for INCORRECT ENGLISH WORD/s] positive beta HCGhCG; [minus 0.5 for CAPITALIZATION ERROR] previous to that, normal menstrual cyclecycles every 28 days. She saidsays [minus 0.5 for WRONG TENSE OF VERB] that she has never had a Pap smear. She was originally seen 2 days ago regarding vaginal bleeding and thought that she had passpassed [minus 0.5 for WRONG TENSE] some tissue. She felt that she probably had spontaneously abortiveaborted [minus 1.5 for INCORRECT ENGLISH WORD] completely. She was told to come to the office in the event of any increaseincreased [minus 0.5 for GRAMMAR ERROR] vaginal bleeding. The bleeding temporized yesterday, but it then became heavy today with a lot of uterine cramps and passing of large clots since and [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] some further tissue -like material in herper vagina. She did not save any of this material for cross us [minus 1.5 for INCORRECT ENGLISH WORD] for examination.
At the time of the office visit today, she was bleeding more than would be usual for her period, with crampy abdominal pain, and the cervical os was opened open and blood clot clots [minus 0.5 for GRAMMAR ERROR] were seemsseen [minus 1.5 for INCORRECT ENGLISH WORD] protruding from the os.
PHYSICAL EXAMINATION
GENERAL: : She is alert and oriented timesx 3 and , in [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] no acute distress.
VITAL SIGNS: Blood pressure 100/66, respirationrespirations 16, pulse 76, temperature 98.6.
PEVIC EXAMINATIONS: Reveals Pelvic examination reveals essentially healthy vagina with blood involved in the vault and [minus 1.5 for INCORRECT ENGLISH WORD] cervical os. The uterus is anteverted, 6 weeks sized and noble. weeks’ size, and mobile. [minus 1.5 for INCORRECT ENGLISH WORD/s] Adnexa are grossly normal. No palpable masses. Rectal examination was negative.
RECTAL EXAMINATIONS: Negative.
I sendsent [minus 0.5 for WRONG TENSE OF VERB] her forfor a sonogram to confirm an incomplete ABabortion, which was confirmed.
PLAN
We: Will [minus 1.5 for INCORRECT ENGLISH WORD] proceed with suctioned suction [minus 0.5 for MINOR ERROR] curettage under general anesthesia. She has been NPO n.p.o. [minus 0.5 for CAPITALIZATION ERROR] since 1:00, and pre operative blood work has been sent, including CBC, Pt, Ptt PT, PTT, [minus 0.5 for CAPITALIZATION ERROR] and urinalysis. She would will be [minus 0.5 for GRAMMAR ERROR] done under outpatient surgery.
line count = 25.49
negative pts. = 16.50 (64%)
ACCURACY = 36%
dERMA 8
BMT – DERMATOLOGY #8
LOD = 1:40
CONSULTATION REPORT
The patient was admitted to the hospital for treatment of Leg a leg ulceration. Consultation was requested specifically for an eruption on the back and legs, which the patient state states [minus 0.5 for GRAMMAR ERROR] has been present in [minus 0.5 for ADDING WORDS NOT DICTATED] 3 months. No treatment has been given for this. The nurses report that the area had been oozing aton the back, but since the start of oral cuplex Keflex, [minus 3.0 for INCORRECT MEDICINE NAME] the oozing has stopped. The patient is not a good historian, state and states only that the eruption started about 3 months ago, and it is occasionally pruritic.
PHYSICAL EXAMINATION
Physical Examinationexamination showed, covering most of the back and also the medial central buttocks, confluent, erythematous, scaly plaqueplaques with some crusting, similar plaque. Similar plaques were also present on the anterior lower legs.
IMPRESSION Confluent: My impression is confluent psoriasis which hashad been secondarysecondarily [minus 0.5 for MINOR ERROR] infected.
PLAN
1. The cuplexKeflex should be continued to treat the secondary infection.
2. The psoriasis will be treated with a combination of 10% LCD in L.C.D. and [minus 0.5 for WRONG CONJUNCTION] 0.1% Triamcinolonetriamcinolone [minus 1.5 for CASING OF MEDICATIONS] cream.
line count = 14.70
negative pts. = 6.50 (44%)
ACCURACY = 56%
LOD = 1:40
CONSULTATION REPORT
The patient was admitted to the hospital for treatment of Leg a leg ulceration. Consultation was requested specifically for an eruption on the back and legs, which the patient state states [minus 0.5 for GRAMMAR ERROR] has been present in [minus 0.5 for ADDING WORDS NOT DICTATED] 3 months. No treatment has been given for this. The nurses report that the area had been oozing aton the back, but since the start of oral cuplex Keflex, [minus 3.0 for INCORRECT MEDICINE NAME] the oozing has stopped. The patient is not a good historian, state and states only that the eruption started about 3 months ago, and it is occasionally pruritic.
PHYSICAL EXAMINATION
Physical Examinationexamination showed, covering most of the back and also the medial central buttocks, confluent, erythematous, scaly plaqueplaques with some crusting, similar plaque. Similar plaques were also present on the anterior lower legs.
IMPRESSION Confluent: My impression is confluent psoriasis which hashad been secondarysecondarily [minus 0.5 for MINOR ERROR] infected.
PLAN
1. The cuplexKeflex should be continued to treat the secondary infection.
2. The psoriasis will be treated with a combination of 10% LCD in L.C.D. and [minus 0.5 for WRONG CONJUNCTION] 0.1% Triamcinolonetriamcinolone [minus 1.5 for CASING OF MEDICATIONS] cream.
line count = 14.70
negative pts. = 6.50 (44%)
ACCURACY = 56%
HEMATOLOGY 8
BMT RED – HEMATOLOGY #8
LOD = 2:16
CONSULTATION
This patient was seen by me with complaints of feeling unusually tired for about two 2 months, of being unable to concentrate, and of having a swollen cervical gland. She denied headache headaches, vertigo, anorexia, bowel irregularities, abdominal pain, skin rashes rash, menstrual irregularities, sore throat, cough, rhinitis, or insomnia.
She had been napping a lot in the day time. daytime. She had had some mild back pain and urinary frequency the week before but none at the time. She denied using tobacco, alcohol, or any drugs, either prescribed or other one.otherwise. [minus 0.5 for GRAMMAR ERROR] There is no family history of diabetes, her diabetes. Her father died of bleeding esophageal varices, she varices. She had some palpitation palpitations before the end of last year, which she saw you about, and she also had a febrile illness a few weeks ago, which she saw you about and which was diagnose diagnosed [minus 0.5 for WRONG TENSE OF VERB] as an acute viral infection or cold flu. “flu.” [minus 0.5 for ADDING WORDS NOT DICTATED]
PHYSICAL EXAMINATION
VITAL SIGN: Temperature On examination she had a temperature of 97 97.4, [minus 3.0 for INCORRECT VALUES] pulse 92, blood pressure 116/70. She was obviously depressed and a little lethargic but cooperative and mentally cleared. clear. Pupils are equally were equal and [minus 1.5 for INCORRECT ENGLISH WORD/s] reactive
FUNDAL: Normal.
HEENT: Unremarkable.. Fundi normal. ENT unremarkable. One or two small anterior cervical nodes, palpable and slightly tendered, tender. [minus 0.5 for MINOR ERROR] Hearing normal bilaterally.
BREAST: Normal.
LUNGS: Clear.
HEART: Regular Breasts normal. Lungs clear. Heart regular without murmurs, clits clicks, [minus 1.5 for INCORRECT ENGLISH WORD] or rubs
ADBOMEN: Soft
SCAPULA: [minus 1.5 for INCORRECT ENGLISH WORD] Non-tendered [minus 1.5 for INCORRECT ENGLISH WORD] rubs. Abdomen soft, scaphoid, nontender, without masses.
EXTREMITIES: Normal.
DEEP TENDON REFLEXES: Normal, bilateral equal.
ROMBERGS TEST: Negative.
Patient was advice [minus 0.5 for WRONG TENSE OF VERB] Extremities normal. Deep tendon reflexes normal, bilaterally equal. Romberg was negative. The patient was advised that she probably had no organic illness but the that laboratory studies willwould be done. To our surprise she showed a 50% lymphocyte count (68 typical) (6 atypical) [minus 1.5 for INCORRECT ENGLISH WORD/s] on her differential and a positive mono test. The hetero file heterophile [minus 1.5 for MISSPELLED MEDTERM] was weekly weakly [minus 1.5 for INCORRECT ENGLISH WORD] positive at 1-56, total 1:56. Total [minus 1.5 for INCORRECT ENGLISH WORD] white count was 9,762. 9762. [minus 0.5 for STYLES ERROR] Urinalysis and chemistry profiles were negative. When I saw the patient today, I told her that the laboratory studies are compatible with either an [minus 1.0 for OMITTED DICTATED WORDs] incipient case of mononucleosis or one that is just wearing down. In the light of her history, the later latter [minus 1.5 for INCORRECT ENGLISH WORD] is surely more likely. I told her mother this two, already this, too. Already [minus 1.5 for INCORRECT ENGLISH WORD] today the patient looks more cheerer chipper and alert and in better spiritspirits, even though I gave her no medicine.
line count = 32.20
negative pts. = 20 (62%)
ACCURACY = 38%
LOD = 2:16
CONSULTATION
This patient was seen by me with complaints of feeling unusually tired for about two 2 months, of being unable to concentrate, and of having a swollen cervical gland. She denied headache headaches, vertigo, anorexia, bowel irregularities, abdominal pain, skin rashes rash, menstrual irregularities, sore throat, cough, rhinitis, or insomnia.
She had been napping a lot in the day time. daytime. She had had some mild back pain and urinary frequency the week before but none at the time. She denied using tobacco, alcohol, or any drugs, either prescribed or other one.otherwise. [minus 0.5 for GRAMMAR ERROR] There is no family history of diabetes, her diabetes. Her father died of bleeding esophageal varices, she varices. She had some palpitation palpitations before the end of last year, which she saw you about, and she also had a febrile illness a few weeks ago, which she saw you about and which was diagnose diagnosed [minus 0.5 for WRONG TENSE OF VERB] as an acute viral infection or cold flu. “flu.” [minus 0.5 for ADDING WORDS NOT DICTATED]
PHYSICAL EXAMINATION
VITAL SIGN: Temperature On examination she had a temperature of 97 97.4, [minus 3.0 for INCORRECT VALUES] pulse 92, blood pressure 116/70. She was obviously depressed and a little lethargic but cooperative and mentally cleared. clear. Pupils are equally were equal and [minus 1.5 for INCORRECT ENGLISH WORD/s] reactive
FUNDAL: Normal.
HEENT: Unremarkable.. Fundi normal. ENT unremarkable. One or two small anterior cervical nodes, palpable and slightly tendered, tender. [minus 0.5 for MINOR ERROR] Hearing normal bilaterally.
BREAST: Normal.
LUNGS: Clear.
HEART: Regular Breasts normal. Lungs clear. Heart regular without murmurs, clits clicks, [minus 1.5 for INCORRECT ENGLISH WORD] or rubs
ADBOMEN: Soft
SCAPULA: [minus 1.5 for INCORRECT ENGLISH WORD] Non-tendered [minus 1.5 for INCORRECT ENGLISH WORD] rubs. Abdomen soft, scaphoid, nontender, without masses.
EXTREMITIES: Normal.
DEEP TENDON REFLEXES: Normal, bilateral equal.
ROMBERGS TEST: Negative.
Patient was advice [minus 0.5 for WRONG TENSE OF VERB] Extremities normal. Deep tendon reflexes normal, bilaterally equal. Romberg was negative. The patient was advised that she probably had no organic illness but the that laboratory studies willwould be done. To our surprise she showed a 50% lymphocyte count (68 typical) (6 atypical) [minus 1.5 for INCORRECT ENGLISH WORD/s] on her differential and a positive mono test. The hetero file heterophile [minus 1.5 for MISSPELLED MEDTERM] was weekly weakly [minus 1.5 for INCORRECT ENGLISH WORD] positive at 1-56, total 1:56. Total [minus 1.5 for INCORRECT ENGLISH WORD] white count was 9,762. 9762. [minus 0.5 for STYLES ERROR] Urinalysis and chemistry profiles were negative. When I saw the patient today, I told her that the laboratory studies are compatible with either an [minus 1.0 for OMITTED DICTATED WORDs] incipient case of mononucleosis or one that is just wearing down. In the light of her history, the later latter [minus 1.5 for INCORRECT ENGLISH WORD] is surely more likely. I told her mother this two, already this, too. Already [minus 1.5 for INCORRECT ENGLISH WORD] today the patient looks more cheerer chipper and alert and in better spiritspirits, even though I gave her no medicine.
line count = 32.20
negative pts. = 20 (62%)
ACCURACY = 38%
Thursday, May 7, 2009
01 BMT Dermatology 8 Consultation
BMT – DERMATOLOGY #8
LOD = 1:40
CONSULTATION REPORT
The patient was admitted to the hospital for treatment of Leg (a leg) ulceration. Consultation was requested specifically for an eruption on the back and legs, which (the) patient (state) states [minus 0.5 for GRAMMAR ERROR] has been present (in) [minus 0.5 for ADDING WORDS NOT DICTATED] 3 months. No treatment has been given for this. The nurses report that the area had been oozing aton the back, but since the start of oral cuplex (Keflex), [minus 3.0 for INCORRECT MEDICINE NAME] the oozing has stopped. The patient is not a good historian, state (and states) only that the eruption started about 3 months ago(,) and (it) is occasionally pruritic.
(PHYSICAL EXAMINATION)
Physical Examination(examination) showed, covering most of the back and also the medial central buttocks, confluent, erythematous, scaly plaque(plaques) with some crusting, similar plaque. (Similar plaques)were also present on the anterior lower legs.
IMPRESSION (Confluent): My impression is confluent psoriasis which has(had) been secondary(secondarily) [minus 0.5 for MINOR ERROR] infected.
PLAN
1. The cuplex(Keflex) should be continued to treat the secondary infection.
2. The psoriasis will be treated with a combination of 10% (LCD in L.C.D. and) [minus 0.5 for WRONG CONJUNCTION] 0.1% Triamcinolone(triamcinolone) [minus 1.5 for CASING OF MEDICATIONS] cream.
line count = 14.70
negative pts. = 6.50 (44%)
ACCURACY = 56%
LOD = 1:40
CONSULTATION REPORT
The patient was admitted to the hospital for treatment of Leg (a leg) ulceration. Consultation was requested specifically for an eruption on the back and legs, which (the) patient (state) states [minus 0.5 for GRAMMAR ERROR] has been present (in) [minus 0.5 for ADDING WORDS NOT DICTATED] 3 months. No treatment has been given for this. The nurses report that the area had been oozing aton the back, but since the start of oral cuplex (Keflex), [minus 3.0 for INCORRECT MEDICINE NAME] the oozing has stopped. The patient is not a good historian, state (and states) only that the eruption started about 3 months ago(,) and (it) is occasionally pruritic.
(PHYSICAL EXAMINATION)
Physical Examination(examination) showed, covering most of the back and also the medial central buttocks, confluent, erythematous, scaly plaque(plaques) with some crusting, similar plaque. (Similar plaques)were also present on the anterior lower legs.
IMPRESSION (Confluent): My impression is confluent psoriasis which has(had) been secondary(secondarily) [minus 0.5 for MINOR ERROR] infected.
PLAN
1. The cuplex(Keflex) should be continued to treat the secondary infection.
2. The psoriasis will be treated with a combination of 10% (LCD in L.C.D. and) [minus 0.5 for WRONG CONJUNCTION] 0.1% Triamcinolone(triamcinolone) [minus 1.5 for CASING OF MEDICATIONS] cream.
line count = 14.70
negative pts. = 6.50 (44%)
ACCURACY = 56%
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