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%