Thursday, February 19, 2009


He was brought to the emergency room with a right epistaxis with clots in the nose. Patient is on Coumadin.

EXAMINATION: Clots were removed from the right nostril, and an active venous bleeder on the right anterior septum was identified. This was cauterized with silver nitrate and an anterior pack placed. The left side appeared to have no active bleeding. He was observed for a few minutes, and no further bleeding of an active nature was identified. Some tape as couterpressure was applied to the nose, and the throat checked also. There is just an old clot posterior that’s sticking down just enough so that you can see it but cannot reach it with an instrument. This was left in place. I recommend that we leave the pack in until Wednesday morning if patient tolerates it. He is apparently already on antibiotics, pain medicines, and oxygen, so no additional orders are indicated at this time.



PATIENT: Brenda Seggerman
Hospital Number: 903321
DATE OF ADMISSION: March 27, 2008
ADMITTING DIAGNOSIS: Ectopic pregnancy

CHIEF COMPLAINTS: The patient presents to the emergency room this morning complaining of lower abdominal pain.

HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she state that she is sexually active and using no birth control.

GYNECOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother.

PAST MEDICAL HISTORY: Positive for Hepatitis-B.

PAST SURGICAL HISTORY: Pilonidal cyst, remove in the remote past. Had plastic surgery on her ears as a child.

SOCIAL HISTORY: Married, has one daughter, patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies ETOH. Smoked marijuana last night. No IV drug abuse.

ALLERGIES: Tightness.


Patient complaints of a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. The patient is also having some nausea and vomiting. Denies hematemesis, hematokesia and melena. The patient has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgias. Review of system is otherwise essentially negative.

VITAL SIGNS: Shows temperature 97degrees, pulse 53, respirations 22, blood pressure 108/60.
GENERAL: Physical examination reveals a well developed, well-nourish, 35-year-old white female in a moderate amount of distress at the time of the examinations.
HEENT: Unremarkable except for poor dentition.
NECK: Soft and supple.
CHEST: Lungs are clear in all fields.
HEART: Regular rate and Rhythm.
ABDOMEN: Soft with positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right.
VAGINAL EXAMINATION: The cervix is close. A moderate amount of mucopurulent vaginal discharge is noted. The patient would not allow me to perform a bi-manual examination due to the patient pain. So the speculum was withdrawn.
EXTREMITIES: No clot. No edema.
NEUROLOGIC EXAMINATION: Intact. Oriented x3, No neurologic deficits.

ADMISSION: Hemoglobin 12.8 g and Hematocrit 36.6%.
URINALYSIS: Essentially Negative.
BETA HCG: Positive with WBC count of 23,278.

Pelvic Ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 mg, and Phenergan 25 mg. IV for the pain after her report was obtained. The patient also given claperan 1g IV.

I page Dr. Gerard, patient’s GYN, physician, as soon as I receive the ultra-sound report at approximately 10a.m. He was not in North Miami office. I page the South Miami office and reach Dr. Gerard’s office at approximately 10:15a.m. His office personnel advice me that he is not on call, Dr. Bomback is on call. I spoke with Dr. Bomback at approximately 10:25a.m. and she will be here to take the patient to the operating room.

ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy.
Disposition: The patient receive and IV of lactated ringer upon arrival at the emergency room. This was switch to normal saline while we were awaiting Dr. Bomback’s arrival. The surgical procedure was explained to the patient and her husband. All risk and benefits were discussed. They understand the necessity for immediate surgery and informed consent was signed. No old records are available for review.



Score: 72



HOSPITAL NO.: 1728456

DATE OF BIRTH: October 25, 1985

DATE OF TRANSFER: November 24, _____

DATE OF ADMISSION: November 25, _____

AGE: 12

Wechsler Intelligence Scale for Children, III
Woodcock-Johnson Individual Achievement Test
(administered by hospital personnel)
Bender-Gestalt Test of Visual Motor Integration
House-Tree-Person Drawing
Thematic Apperception Test
Rorschach Inkblot Technique
The patient was referred for assessment by Dr. Rosemary Lowenthal, child psychiatrist, Johnston Recovery Center. Specific information was requested regarding intellectual potential, achievement, and current personality features.

The patient is a 12-year-old black female who was admitted to the Children's Treatment Unit at Johnston Recovery Center on November 25 because of severe behavioral problems, school problems, low self-esteem, physical aggression toward others, and problems related to past sexual abuse. The patient was brought to Johnston Recovery Center by her grandmother who has physical custody of her at this time. The patient denied suicidal/homicidal ideations as well as visual and auditory hallucinations. She was reportedly severely sexually molested and abused by her older brothers when she was 6 years of age. It is reported that her brothers shoved sticks and bottles up her vagina and that one of her brothers sodomized her. This individual is currently incarcerated at Barchfield Training School. The patient comes from a family of 6 siblings, and all siblings are separated from the home of their parents other than 1. The patient was removed from the home subsequent to the discovery of the abuse and remained in a shelter until age 9 when she was moved and placed in the custody of her grandmother. The patient currently lives within 2 miles of her natural parents' home. She is said to be involved with both her parents and to get along with them adequately. A conflictual relationship is said to exist between the patient and her grandfather who reportedly resents her presence. The patient reportedly failed the first grade and attends "LD classes." The patient began walking at about 13 months of age and had difficulty with speaking until the age of three. She had difficulty with toilet training and continued to wet her pants until she was 4 years of age.
The patient is said to have difficulties at school including inattention and poor listening skills. She has attacked another student at school physically. She has also displayed herself inappropriately in front of men and boys. The patient is said to have dental problems and is currently receiving treatment for her problems. She is said to have chest pain frequently when she exercises. Frequent headaches are reported. The patient is said to eat too frequently and gains weight easily. She is said to binge on food if the food is available. She complains of stomachaches frequently. The patient has few sleep difficulties at this time but is reported to have had nightmares frequently in the past. The patient is said to have one friend at school who is 9 years of age. Others have reported that she has low self-esteem. She has reportedly received treatment at a mental health center at Atkins.

The patient presented as an obese 12-year-old black female with black hair and brown eyes. She was dressed appropriately on the day of the evaluation, and she did not wear glasses or hearing aids. The patient reported to the examiner that "I did this 2 years ago at
Miss Amanda's office," in reference to the assessment tasks given her. The patient's fingernails were bitten and chewed to the quick. The patient seemed to have problems listening on occasions during the assessment, and she frequently asked to have items repeated to her. During several difficult assessment tasks, the patient looked at the examiner with a shy smile as she was completing the items as if to express pride that she had completed difficult items. She engaged in self-deprecatory comments from time to time, and she had to be encouraged to work on difficult items. She was very flat initially but began to smile occasionally toward the latter part of the assessment. She turned her chair away from the examiner and refused to maintain eye contact while elements of her past history were discussed. She clearly felt uncomfortable and was unresponsive. The test results obtained during this assessment appear to be valid estimates of her functioning.

Information 4 Picture Completion 7
Similarities 5 Coding 5
Arithmetic 7 Picture Arrangement 5
Vocabulary 6 Block Design 8
Comprehension 1 Object Assembly 9
VERBAL IQ 70 Factor Scores:
PERFORMANCE IQ 80 Verbal Comprehension 68
FULL SCALE IQ 73 Perceptual Organization 85
Freedom from Distractibility 78
Based on the scores obtained by the patient on this instrument, she is apparently functioning overall within the borderline range of potential. A nonsignificant 10-point difference between verbal and performance scores was noted. The difference between the patient's perceptual organization factor score and her verbal comprehension factor score, however, was statistically significant. This suggests that the patient may be more efficient in completing tasks which require her to use visual or performance abilities. The patient scored highest on the subtest measuring her ability to put together puzzles of familiar objects. She scored lowest on the subtest measuring common sense reasoning about everyday problems and concerns.
Letter Word Identification: 18 1.2 58 3
Passage Comprehension: 10 1.6 71 3
Math Calculation: 10 2.2 64 1
Applied Calculation: 27 2.6 85 16
Dictation: 17 1.6 72 3
Writing: 15 2.4 84 15
Based on the scores obtained by the patient on this instrument, she is apparently functioning within the low-average range in math reasoning and writing, within the borderline range in reading comprehension and spelling, and within the deficient range in math calculation. Very deficient functioning was noted in letter word identification.

The patient completed the Bender task in 2 minutes 50 seconds, which is somewhat quicker than typical for task completion. She earned 2 errors using the Koppitz scoring system. This score is roughly age-appropriate and suggests adequate visual motor integration skills for her age.

The patient completed a drawing with the required picture elements. Her picture elements were very large and dominated the page. They were drawn in a quick manner with broad sweeping strokes. Several picture elements were heavily shaded while others were drawn with no apparent regard for boundaries. There were multiple windows in the house. Her drawing suggests poor behavioral controls as well as poor boundaries and limits. Aggressive behavior appears to be likely. The story told by the patient accompanies her picture suggests that she prefers to relate to her mother at times and that she is likely to display regressive needs. It appears that the patient is attempting to meet needs for support and care which she does not feel were satisfied at appropriate developmental levels.
Stories told by the patient to accompany the TAT material suggests the 5 following clinical hypotheses: The patient seems to see relationships as conflictual and untrustworthy. She seems to see the world as a threatening and dangerous place for her. She told stories which suggest that there is strong conflict among members of her family. She seems to be quite concerned regarding issues which were raised when she was removed from the care of her mother. There seem to be several unresolved matters which may date from the incidents or series of incidents. There were some indications of possible suicidal thought as well as likelihood that she demonstrates oppositional behavior toward her mother and her influence over her. She seems to understand the relationship problems in her family are solved by violence and has been solved by violence or aggression between individuals. Consequently, she seems to be maintaining only a superficial control over considerable anger and aggression.

The responses provided by the patient to the Rorschach suggest the following clinical hypotheses. The patient appears to look at the world in somewhat unusual ways. She does tend to focus on concrete and practical matters and is considered to be psychologically conservative. She probably exhibits poorly controlled emotions and is somewhat activated by emotionally charged events in her surroundings. She probably is defensive and has relatively poor intellectual and psychological resources to cope with complex surrounding events. Her reality testing and perceptual accuracy were poor.

AXIS I: Oppositional defiant disorder, dysthymia, grandparent/child problem, and sexual abuse.
AXIS II: Reading disorder and rule out mathematics disorder.

The patient is a 12-year-old black female who was admitted to the Children's Treatment Unit at Johnston Recovery Center on November 25 because of increasing behavioral problems, school problems, low self-esteem, increasing physical aggression, and past sexual abuse. The patient is currently being cared for by her grandmother who has physical custody of her. The patient was removed from her home when she was 6 years of age after molestation and sexual abuse was discovered. It is reported that several of the patient's brothers were engaging in sexual activities including inserting objects in her vagina and sodomizing her. One of her older brothers is currently incarcerated in Barchfield Training School. Other male siblings are not living in the home of their natural parents at this time. The patient reportedly lived in a shelter for several years after being removed from her home and was only recently placed in her grandmother's custody. The patient has had difficulty at school including poor attention focus and aggression toward other children. She has had academic problems from the first grade and is reportedly attending learning disability classes at this time. The patient walked at 13 months of age and had problems speaking until the age of 3. She also had delayed toilet training. The patient is obese, complains of chest pains during exercise, and has dental problems. She has frequent headaches, binges on food if it is available, and has no sleep difficulty. She has been treated at the mental health center at Atkins.
Based on the information gathered during this assessment, the patient apparently functions intellectually overall within the borderline range. Her score patterns suggest that deficient skills are present in verbal language areas and that low-average skills are present in visual perceptual areas. The patient scored within the low- average range in math reasoning and writing, within the borderline range in treading comprehension and spelling, and within the deficient range in math calculation. Reading recognition was measured within the very deficient range. Visual motor integration skills were measured as being commensurate with current intellectual potential. Personality features identified during the assessment include a concrete and practical or psychological conservative approach to surrounding events with little psychological sophistication. Defensiveness and an atypical way of looking at her surroundings was also noted. Poorly controlled emotions and significant underlying aggression was identified. Significant issues related to family issues and relationships appear to be present.

Based on the information gathered during this assessment, the following recommendations appear to be appropriate:

1. The patient appears to need continued hospitalization in the Children's Treatment Unit at the Johnston Recovery Center in order to take full advantage of the treatment milieu provided there.

2. The patient appears to have learning disabilities in reading and possible math calculations. The current test results may be submitted to the special education program developer in the school district where she currently attends school so that a proper educational program may be planned for her after discharge.

3. The patient will probably be a superficially cooperative participant in therapeutic activities. If she is pressed to discuss issues regarding her past which she considers to be personal, then she may become noncompliant and even combative. She should
respond well to behavioral management approaches which emphasize rewards and secondary reinforcers such as praises and verbal accolades. Further investigation of family functioning should be undertaken with an attempt to provide the patient with a
nonconflictual environment. The patient will likely continue to have difficulties with adjustment if the apparently dysfunctional relationships displayed for her by significant family members are not addressed directly.

Pulmo 8


This is a 32-year-old white male, lifelong nonsmoker, referred to me. He complains of a less than 2-weeks history of dry cough associated with dull substernal discomfort and dyspnea, particularly on exertion. Otherwise, he has been remarkably free of any other associated symptoms. In particular, he denies any preceding cold or flu or allergic exposure, and denies any associated fevers, chills, sweats, or weight loss. He does admit to having childhood asthma but felt he grew out this by the time he was a teenager. He was traveled extensively outside the U.S., including travel to the California deserts and Central Valley. He has not had pneumonia vaccine. He did have TB skin test 10 years ago and did have flue vaccine 3 years ago.

PAST MEDICAL HISTORY: Past medical history is remarkably negative.

PHYSICAL EXAMINATION: Blood pressure 140/80, pulse 85, respiratory rate 22, temperature 99.3.Chest exam is complete normal. There are no rales, wheezes, rhonchi, rubs. Even on forced exhalation, there was no cough or prolongation. Cardiac exam showed a regular rate and rhythm with no murmur or gallop.

LABORATORY DATA: PA chest x-ray is striking for a new interstitial infiltrate seen on both midlung zones with some shagging of the cardiac borders, indicating involvement of the lingual and right middle lobe. Surprisingly, the lowest part of the lung fields and the apices appear to be spared. Spirometry before and after bronchodilator performed in my office show a vital capacity of 3.79 or 69% after an 11% improvement with bronchodilator. FEV-1 achieves 3.24 L or 72% of predicted after 12% improvement wih bronchodilator. FEV-1/FVC ratio was mildly increased at 85 instead of predicted 82.

ASSESSMENT AND PLAN: Differential diagnosis includes the following:
1. Hypersensitivity pneumonitis.
2. Mycoplasma pneumonia.
3. Less likely candidates appear to be Wegener’s granulomatosis, Goodpasture’s syndrome, sarcoidosis, alveolar proteinosis, and allergic bronchopulmonary aspergillosis.

1. CBC, differential, chemistry-20, Wintrobe sed rate, angiotensin converting enzyme, urinalysis, and Mycoplasma titers.
2. Full pulmonary function test within 2 weeks
3. Vibramycin 100 mg q. day for 14 days. If he still has significant symptoms and restriction on PFTs within 2 weeks, he will have to be evaluated for one of the more chronic diagnoses, which may ultimately require open lung biopsy. Otherwise we should hope that within 2 weeks the patient will be improved and his x-ray will have cleared.

Pulmo 5


HISTORY OF PRESENT ILLNESS: Patient is a one-year-old female that has been congested for several days. The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago. Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving. Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

GENERAL: Physical exam in the ER showed an alert child in moderate respirator distress.
VITAL SIGNS: Respiratory rate was 40, pulse 20, temperature 99.6.
HEENT: Within normal limits.
NECK: Positive for mild to moderate stridor.
CHEST: Chest showed a diffuse inspirator and expiratory wheezing. No rales were noted. Viewing the chest wall, patient had subcostal-intercostal retractions.
HEART: Regular rhythm without murmur, gallop, or rub.
ABDOMEN: Soft, nontender, bowel sounds normal.
EXTREMITIES: Within normal limits.

The child was sent for a PA and lateral chest x-rays to rule out pneumonia. No pneumonia was seen on the films.
It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3 h. The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

1. Acute laryngotracheobronchitis.
2. Bronchial asthma.

Introduction to MS Word

Getting Started with Microsoft Word
This handout provides an introduction to the fundamentals of Microsoft Word. It covers starting Word, the Word interface, creating a Word document, editing a Word document, selection techniques, paragraph and character formatting, spell checking, printing, graphics and tables.
Starting Word
1. On the PC, select Start, Programs, and Microsoft Word from the Start list.

2 Double-click on the icon of any Word document. Word documents can be anywhere. Word opens with the selected document already loaded.

Exploring the Word Interface

Components of the Word Window
Besides the usual PC window components (close box, title bar, scroll bars, etc.), a Word window has other elements, as shown in the following figure.

Component Functionality or Purpose of the Component
Menu Bar Contains File,Edit, View, Insert, Format, Tools, Table, Window and Help menus
Standard Toolbar Contains icons for shortcuts to menu commands.
Formatting Tool Bar Contains pop-up menus for style, font, and font size; icons for boldface, italic, and underline; alignment icons; number and bullet list icons; indention icons, the border icon, highlight, and font color icons.
Ruler Ruler on which you can set tabs, paragraph alignment, and other formats.
Insertion Point Blinking vertical bar that indicates where text you type will be inserted. Don't confuse the insertion point with the mouse I-beam. To move the insertion point, just click the mouse where you want the point moved.
End-of-File Marker Non-printing symbol that marks the end of the file. You cannot insert text after this mark.
Selection Bar (Gutter) Invisible narrow strip along the left edge of the window. Your mouse pointer changes to a right-pointing arrow when it is in this area. It is used to select a line, a paragraph, or the entire document.
Split Handle Double-click to split the window in two (to view different portions of the same file). Double-click to return to one window
Status Bar Displays page number, section number, and total number of pages, pointer position on page and time of day.
Task Pane Displays and groups commonly used features for convenience.
Office Assistant An animated character that can provide help and suggestions. There are multiple characters to choose from, and it is possible to turn the Office Assistant off.

Creating and Saving a Document
Opening and Closing A Document
To open a file, select Open... from the File menu. In the dialog box, click on the filename and then on the Open button. If your file is not in the opened folder, click on the down arrow (next to folder name) to see a directory listing. The Up One Level button icon on the right enables you to move up one level. You can then switch to the floppy disk, hard drive or Desktop where the appropriate file or folder is located.

For example, to open a file from a floppy disk, select Open... from the File menu. If the disk's name does not appear on the left side of the dialog box, click on the down arrow. Select its name in the box at the left or if it is not displayed, click the Up One Level button to see a different display of files and folders. When you locate the desired diskette or file, click Open. (Double-clicking on the name will also open it).
To close a document, click its close box in the upper right of the title bar (box with the large X on it) or select Close from the File menu. The keyboard shortcut is .
Saving a Document
Your document and changes you make to a document are not saved to disk until you issue a save command. Saving is quick and easy. You should save often to minimize the loss of your work. Word has two save commands - Save and Save As. - that work similarly. Both are under the File menu.
Save Save As
When you save a new document for the first time, Word displays a dialog box (see figure, below). Select where you want to save your document and give it a name. When you save an existing document that you have been editing, the newly saved version is written over the older version. This command always displays a dialog box where you can choose a document name and disk (see figure, below). Use the Save As. command whenever you want to save a copy of the current document under a different name or in a different folder (or disk). The newly saved copy becomes the active document.
Adding and Modifying Text
Entering Text
To enter text, just start typing. Word inserts the text you type at the insertion point. If you press a wrong key, use the Delete key to erase the mistake. Word automatically starts a new line when you reach the end of the current line. This is called "word wrap". Do not press Enter at the end of a line. Press Enter only at the end of paragraphs.

Type the following paragraph. Remember, don't press Enter at the end of the line.
Microsoft Word is part of the Microsoft Office software. It allows you to create, edit, modify and enhance documents. Word is not a simple text processor. It is a document production system.
To move the insertion point with the mouse, click the mouse in the desired location. If the location you want is not visible, use the scroll bars to move up or down in the document. To move the insertion point to the top of the document, press . To move to the end of the document, press < Ctrl + End >.
To insert new text, just click the mouse at the point where you want to insert the additional text and start typing. Existing text moves to accommodate your additions.
Click the mouse pointer after the word, "enhance" and type:
Click the mouse pointer before the word, "not" in the second line and type:
Type to move to the very beginning of your document and type:
Your name and press Enter .
Today's date and press Enter
The name of the school where you teach and press Enter, Enter.
Deleting Text
The Backspace key deletes one character to the left of the insertion point. The Delete key deletes one character to the right of the insertion point. You can use these keys any time. To delete more than just a few characters, select the text and press the Delete key. Selecting text is covered below.
Undoing Mistakes
If you make a terrible mistake-you accidentally delete an important paragraph, for example-use the Undo command under the Edit menu immediately (The keyboard shortcut is < Ctrl + Z >). Do not issue any other command until after you have undone your mistake.
Selecting Text to Bold, Italicize, and Underline
You select a portion of text in order to perform some operation on it. You can then delete, replace, copy, move, or format it. The Selection Bar is located to the left of the document window. When you put your mouse pointer, which is a left pointing arrow in that area, the arrow swings to the right. The following table explains how to select various blocks of text.

To Select this... Do this...
Word Double click anywhere on the word.
Line Click right-pointing arrow in the selection bar to left of line.
Sentence anywhere in sentence.
Paragraph Double-click the right-pointing arrow in the selection bar to the left of the paragraph, or triple-click in paragraph.
A block of text of any size Click at one end of the block and shift-click at the other end of the block. Or click at one end of block and drag to the other end of the block.
Entire document Press < Ctrl + A> or hold down the Ctrl key and click in the selection bar.
And to... Do this...
Deselect text Click anywhere outside the selection.
Extend a selection Shift-click an additional block. For example, if you have selected a paragraph and you shift-click on another paragraph, it will be added to the selection.
Copy and Paste Text
You can copy selected text from one place to another with the Copy and Paste commands or with the Drag and Drop procedure. You can move selected text from one place to another with the Cut and Paste commands, and with the Drag and Drop procedure. These commands and procedures are described below.
Cut - The Cut command extracts the selected text and puts it on the Clipboard (a temporary storage area). The contents of the Clipboard are overwritten with each copy or cut.
Copy - The Copy command puts a copy of the selected text on the Clipboard.
Paste - The Paste command inserts the Clipboard's contents at the insertion point. Existing text moves to accommodate pasted text. If text is selected, it is replaced by the pasted text.
Drag and Drop - This procedure does not involve the Clipboard and works best when moving text a short distance. To move text, select the text and drag it to its new location. To copy text; hold down the key while you drag the text.
Check the Spelling
Word has a built-in spelling checker. You can have Word check a selected portion of your document (one word, a paragraph, etc.) or the entire document. If you select text before starting the spelling checker, Word checks the selection, then asks whether it should stop or check the rest of the document. To check the entire document, move the insertion point to the top of the document ( Ctrl + Home) before you select the spelling checker.
To start the spelling checker, select Spelling and Grammar from the Tools menu. Word will begin to check for misspellings. If Word finds a word that is not in its dictionaries, it pauses, displays the word, and if possible, suggests alternatives (see figure below).
You have several choices at this point described in the table below. If the word is spelled correctly, you can have Word ignore it or add it to a custom dictionary. If the word is incorrect, you can have Word replace it with one of its suggestions or with a spelling you supply in the Change To: box.

If the word is spelled correctly...
To ignore only this occurrence of the word, click Ignore
To ignore all occurrences of the word, click Ignore All
To add the word to a custom dictionary, click Add
If the word is misspelled...
First, click correct spelling in Suggestions list or type the correction in the Change To: box. Then...
To change only this occurrence of the word, click Change
To change all occurrence of the word, click Change All
After you make your choice, Word continues checking spelling. Remember to save your document after using the spelling checker in order to retain the changes.
Formatting Text and Paragraphs
Formatting Text
You can format text that you are about to type or text that already exists. To format new text, turn on the formatting features you want, type the text, and then turn off the features (select them again or select new features). To format existing text, select the text and choose the formatting features. For example, to create a heading that is Helvetica, bold, 18-point text, select the font and size from the pop-up menus on the Tool Bar (see below). Then, click on the B button to turn on bold.
Formatting Paragraphs
In Microsoft Word , a paragraph is any amount of text followed by a paragraph symbol (¶). A one-word heading is a paragraph. A 100-word job description is a paragraph. Even a blank line terminated by a ¶ is a paragraph.
You can perform paragraph formatting from the Format menu.

You can also choose icons from the Formatting Tool Bar to format paragraphs.
1. Font and font sizes,
2. Paragraph alignment icons, and
3. Indention icons.
4. Numbered and Bulleted lists.
Using Word’s Multiple Clipboard:
Word uses the MS Office clipboard which allows for multiple items to be stored at the same time (unlike Windows clipboard which only allows 1 item at a time). Word 2000 will store up to 12 items, Word 2002 and 2003 will store up to 24 items. The same clipboard is used in all Office programs (Word, Excel, Outlook, Power Point, etc.), so you can copy from one program and paste into a different program.
1. To place items on the clipboard
a. select the item and copy it as you would to the Windows clipboard
b. to open the multiple clipboard in Office 2002 or 2003 click on the Edit menu Office Clipboard, in Office 2000 click on the View menu  Toolbars  Clipboard
c. Repeat item 2 above until you have several items on the clipboard

2. To paste the items on the clipboard, place your insertion point in the proper position on your document and click on the item to be pasted
Removing formatting
• Click on Undo button (if you just made the change)
• Select the text, and use the formatting commands again to remove formatting
Applying Formatting With The Format Painter
Use the format painter to quickly apply formatting to several pieces of text. Example -- you
have 15 titles within a document and you have just formatted one as Arial, Bold, Centered, 14. It
would be time consuming to select every title then apply the same 4 formatting features. If you use the
Format Painter you apply formatting once and then copy the formatting to the rest of the titles!
1. Select the formatted text
2. Double click on the Format Painter button
3. The mouse pointer turns into an I-beam with a paint brush
4. Select the text through out the document that you want to apply the formatting to.
5. Click once on the Format Painter to turn it off.
Use buttons on the formatting toolbar or the following keyboard combinations to adjust paragraph alignment.
The default alignment for every new Word document is left justified, single spaced.
To change alignment, click within the paragraph (or line of text) then use one of the following methods:

Buttons Keyboard Result

Using The Find And Replace Command

• Edit, Find


1. Edit, Replace
2. Type in the text you are searching for, then strike the Tab key.
3. Type in the replacement text exactly as you want it to appear in the document.
4. Choose Replace All to replace all instances or Find Next and Replace to replace an instance at a time.

Numbering Pages With the Header and Footer
Headers and footers typically contain titles and page numbers for a document. A header is text that appears within the top margin on each page, whereas a footer appears in the bottom margin. You can set a different header and footer on the first page by selecting Page Setup from the File menu, clicking the Layout tab from the open dialog box and then selecting Different First Page from the available options.
To create a header (or footer) in a document, select Header and Footer from the View menu. Type the header or footer text in the header or footer window (see below). The default text is left aligned with a centered tab set at 3 " and a right tab at 6. You can format Header and Footer text using the Ribbon and Ruler similar to a paragraph in your document. Click on the Header and Footer tool bar buttons to insert a page number, the current date, the time, and to switch between the Header and Footer template.

Bullets And Numbering

Automatic Bullets Or Numbers
To create a numbered or bulleted list automatically: Go to Tools AutoCorrect, Choose the AutoFormat As You Type tab. Confirm that Automatic bulleted lists and Automatic numbered lists are checked. Press OK. Position the cursor where you want the list to begin. Enter a number or an asterisk, Press Tab, type the first item in the list, press Enter, Word 2000 automatically starts a bulleted or numbered list for you. To end the list, press enter twice.
Using Proofing Tools

• Move your cursor to the top of the document (ctrl + home)
• Click on either the spell and grammar check button or click Tools, Spelling and Grammar

1. Highlight the word you want to look up.
2. Click on Tools, Language, Thesaurus.
3. Click on a word from the list
4. Select Replace

Understanding the Different Types of Indents
There are 4 different types of indents:
• A Left Indent moves the left margin of a paragraph to the right.
• A First Line Indent moves only the first line of a paragraph to the right
• With a Hanging Indent, the first line aligns on the left and the rest of the paragraph "hangs" from the first line.
• A Right Indent moves the right margin of a paragraph to the left
Indenting Paragraphs Using the Formatting Toolbar
The Indenting buttons on the Formatting toolbar moves the Left Indent Marker in increments of 5 spaces.
1. Select the paragraph(s) you wish to indent.
2. On the Formatting toolbar, do one of the following:

To indent a paragraph: Click:
To the right:

To the left:

Indenting Paragraphs Using the Ruler
1. Select the paragraph(s) that you wish to indent.
2. Drag the Indent Marker (found on the ruler) to indent the paragraph by the appropriate value:

1. To create a First Line Indent, click and drag the First-Line Indent Marker to the right to the desired value.
2. To create a Left Indent, click and drag the Left Indent Marker (the bottom square) to the right.
The entire "hourglass" should move. If it splits as in the photo above, carefully move the marker back to the original position and try again, moving the cursor down slightly to select ONLY the bottom square.
1. To create a Hanging Indent, click carefully on the bottom triangle and drag the Hanging Indent Marker to the right. The"hourglass" will split, as in the photo above.
2. To create a Right Indent, drag the Right Indent Marker to the left of the right margin.
Sometimes unintentional indents are set that go way beyond the left margin. If this should happen, click in the paragraph that is out of line and look at the Ruler. It will probably look something like this.

Try to determine what kind of indent was set. If one part of the indent marker cannot be seen, Click on the left horizontal scroll arrow until the indent marker shows on the ruler. At this point, move the triangle that is out of line so that it lines up with the other at the margin.
Clicking on the right horizontal scroll arrow will realign the page on the screen. If all else fails, click on the Undo arrow until your margins are realigned.
Understanding tabs
When you press the TAB key, the insertion point moves to the next tab stop position and the space is filled with a tab character. By default, tab stops are set at 0.5-inch intervals from the left margin. You can set and change the alignment of tab stops in selected paragraphs. When you set a new tab stop, Word clears any default tab stops to the left of the new tab stop.
1. Decide which tab you would like to insert.
2. There are 2 components of tabs. A tab is inserted into text by pressing the TAB key. Secondly, a tab stop must be set, using either the Ruler or Menu. If there are no tabs set, the cursor will move to the next default tab setting (set at 1/2 inch intervals). Leaders (... between text) can also be set using the Tabs menu.

Although the tab character is always inserted when you press TAB, it can only be viewed when the Show Paragraph command from the Toolbar is turned on. Word has four types of tab stops that can be used to format information more effectively: The diagram below illustrates these tab styles.
4. To insert a tab in your text, click in the text where you wish to insert the tab, press the TAB key.
Setting tab stops and tab leaders using the Tabs menu
1. Select the paragraph(s) that you wish to format with tabs.
2. From the Format Menu, choose Tabs. This will open the Tabs dialog box.
3. At Tab Stop Position:, type the position at which you want to set the tab.
4. At Alignment, click the alignment option.
5. At Leader, click type of leader character, if desired.
1. Leaders are the dashed, dotted, or solid lines that follow the tab. They are used to add visual clarity to text.
6. Click Set.
7. Click OK to close the Tabs dialog box. You should see the tab stop in the Ruler.
Clearing tab stops using the Tabs menu
1. Select paragraph you wish to format.
2. From the Format menu, choose Tabs.
3. To Clear a stop, click on the Tab stop that you wish to clear and click the Clear button. New stops can
4. Click OK.

Setting tab stops using the Horizontal Ruler
1. If the Ruler is not visible in the document window, from the View menu, choose Ruler.
2. Select the paragraphs you wish to set stops.
3. Click the desired tab style from the Tab Alignment button on the Ruler. It will switch between tab styles with each click.
4. On the ruler, place your pointer where you wish to have a tab stop and click. It will leave a tab in that spot. You will also see a vertical dotted line for visual use down your page.
Deleting and moving tab stops using the Horizontal Ruler
1. To move a tab, click on tab mark and drag to desired spot on ruler.
2. To delete a tab, click on tab and drag off the horizontal ruler.
Create Tables in Word
Using tables in Word can be a very convenient way to easily display and organize information in a document.
Microsoft Word offers a number of ways to make a table. The best way depends on how you like to work, and on how simple or complex the table needs to be.
Use the Insert Table Command
Use this procedure to make choices about the table dimensions and format before the table is inserted into a document.
1. Click where you want to create a table.
2. From the Table menu choose Insert, and slide right to Table.
3. Under Table size, select the number of columns and rows.
4. Optional: Under AutoFit behavior, choose options to adjust table size.
5. Optional: To use a built-in table format, click AutoFormat.
6. Select the options you want.
7. Click OK.
Word positions the insertion point in the first cell of the table. You can immediately type text in the table.
Use the Insert Table toolbar button
Use this procedure to make choices about the table dimensions ONLY before the table is inserted into a document.
1. Position the cursor where you want to create a table.
2. On the Standard toolbar, click and hold on the Insert Table button.
a. A grid appears below the button.
3. Drag over the grid until you've selected the number of rows and columns you want.
4. Release the mouse button.

Draw a more complex table
You can draw a complex table — for example, one that contains cells of different heights or a varying number of columns per row.
1. Click where you want to create the table.
2. From the Table menu, choose Draw Table.
a. The Tables and Borders toolbar appears.
b. The pointer changes to a pencil.
3. Click, hold, and drag to define the outer table boundaries.
a. You would want to draw a rectangle.
4. Draw the column and row lines inside the rectangle.
5. When you finish creating the table, click a cell and start typing or insert a graphic.
Note: Hold down CTRL to automatically apply text wrapping while you draw the table.
To erase a line or block of lines:
1. Click Eraser on the Tables and Borders toolbar.
2. Click the line you want to erase.
Text Borders and Shading
You can set apart paragraphs or selected text from the rest of a document by adding borders. You can also highlight text by applying shading.
1. Do one of the following:
a. To add a border to a paragraph, click anywhere in the paragraph.
b. To add a border only to specific text, select the text.
2. On the Format menu, click Borders and Shading, and then click the Borders tab.
a. Select the options you want, and make sure the correct option — Paragraph or Text — is selected under Apply to.
i. To specify that only particular sides get borders, click Custom under Setting. Under Preview, click the diagram's sides, or use the buttons to apply and remove borders.
b. To specify the exact position of the border relative to the text, click Paragraph under Apply to, click Options, and then select the options you want.
Add shading to a table, a paragraph, or selected text
1. To add shading to a table, click anywhere in the table.
a. From the Format menu, choose Borders & Shading.
b. Click on the Shading tab.
c. Select the shade you want. Remember that your text needs to be legible
d. Under Apply to, click the part of the document you want to apply shading to.
i. For example, if you clicked a cell without selecting it in step 1, click Cell. Otherwise, Word applies the shading to the entire table.
2. To add shading to specific cells, select the cells, including the end-of-cell marks.
a. From the Format menu, choose Borders & Shading.
b. Click on the Shading tab.
c. Select the shade you want. Remember that your text needs to be legible
d. Under Apply to, click the part of the document you want to apply shading to.
i. For example, if you clicked a cell without selecting it in step 1, click Cell. Otherwise, Word applies the shading to the entire table.
3. To add shading to a paragraph, click anywhere in the paragraph.
a. From the Format menu, choose Borders & Shading.
b. Click on the Shading tab.
c. Select the shade you want. Remember that your text needs to be legible
d. Under Apply to, click the part of the document you want to apply shading to.

e. For example, if you clicked a cell without selecting it in step 1, click Cell. Otherwise, Word applies the shading to the entire table.
4. To add shading to specific text, such as a word, select the text.
a. From the Format menu, choose Borders & Shading.
b. Click on the Shading tab.
c. Select the shade you want. Remember that your text needs to be legible
d. Under Apply to, click the part of the document you want to apply shading to.
i. For example, if you clicked a cell without selecting it in step 1, click Cell. Otherwise, Word applies the shading to the entire table
Select File, Print to print your document. Save the document before selecting the Print command to avoid losing your work. You can also click on the Print icon to print the active document.
Review and Summary
To... Do This...
Open a Word document. Double-click on the icon.
Open any document within Word Select Open... from the File menu or press < Ctrl + O > . In the dialog box, click on the filename and then on the Open button.
Close a document Click its close box, select Close from the File menu, or press < Ctrl + W>.
Save a document Select Save from the File menu or press < Ctrl + S > . Type a name for the document and select a disk in which to save it.
Move text Select the text. Choose Cut from the Edit menu or press < Ctrl + X>.
Copy text Select the text and choose Copy from the Edit menu or press .
Insert text from the clipboard Choose Paste from the Edit menu or press < Ctrl + V >
Set the margins Choose Page Setup from the File menu.
Change the font or size of text Select the text and choose from the Font or Size boxes on the Ribbon.
Create bold , italic or underlined text Select the text and choose the formatting features from the Ribbon.
Change the alignment or spacing of paragraphs Select the paragraphs and click on the alignment and spacing icons on the Ruler.
Add page numbers Choose Header and Footer from the View menu. Click on the page number icon.
Start the spelling checker Move the insertion point to the top of the document or press < Ctrl + Home>. Select Spelling and Grammar from the Tools menu.
Preview the document Choose Print Preview from the File menu.
Print the document Choose Print from the File menu or press < Ctrl + P >.

Create a Template in Microsoft Word
A template is a form in which the person entering the information is only allowed to manipulate areas that you allow. For instance, the student can type in their name, and the answers to a question, but not edit other text on the page such as a grading rubric.
Some good uses for templates:
• To limit the length of an essay response.
• To save time for your students by allowing them to choose responses from a drop-down box.
• To receive the information you desire in a clean, formatted, consistent manner from every respondent.
To create a Word Template, open Microsoft Word and follow these instructions.
1. You need to create a form, and in order to add form fields, you must have the Forms toolbar available. To view any toolbar, click on the View menu and go down to the Toolbars menu, slide over and select the menu you want to view, in this case Forms.

By selecting a menu there will be a check mark next to it if it is currently open and visible in Word. So, if there is already a check mark next to Forms, then it is already open, you just have to find it. The Forms toolbar looks like this:
Note: The toolbar may be docked, or connected to the typical toolbars that you see in Word, or it might be floating around in the workspace.
2. Type your text into Word, and add form fields where necessary. There are three basic options, a text form field, a drop-down form field, and a check box form field.
To add a text form field:
A text form field is used when you want to allow the user to type in text, as in their name, a paragraph answer to a question, or any other text.
For example, if you want to make a space for your students to enter their names, type Name and then click on the text form field - - on the Forms toolbar. A gray area will show up where your cursor was when you clicked on this button. If you double click on this gray area, the Text Form Field Options window will pop up allowing you to customize the field. The top four fields will be the ones you are most interested in and are explained more below.

• The Type field allows you to choose whether the text entered is regular text, a number, a date, or another specifically formatted type of text.
• The Default text field is where you type in text that will appear in the gray area, giving instruction to the person filling out the template; in this example if you were making a name field you might type in 'enter your name here'.
• The Maximum length field is used if you want to limit how many characters can be entered in the field you are creating. Keep in mind that a space is considered a character.
• The Text format field allows you to specify how you want the text to look after it is entered, you can leave this field blank and the text will appear how it is typed. However, if you choose, Uppercase then no matter what the user types in, the text will appear in uppercase. The other options are lowercase, first capital and title case.
So, if I typed Name and then created a text field next to it for user to type in their name, and set up the default text to read 'enter your name here', and the text format field to first capital, the result in Word would look as follows:



The patient was admitted to the hospital for treatment of Leg ulceration. Consultation was requested specifically for an eruption on the back and legs which patient state has been present in 3 months. No treatment has been given for this. The nurses report that the area had been oozing at the back but since the start of oral cuplex, the oozing has stopped. The patient is not a good historian, state only that the eruption started about 3 months ago and is occasionally pruritic.

Physical Examination showed covering most of the back and also the medial central buttocks, confluent, erythematous, scaly plaque with some crusting, similar plaque were also present on the anterior lower legs.

Confluent psoriasis which has been secondary infected.

1. The cuplex should be continued to treat the secondary infection.
2. The psoriasis will be treated with a combination of 10% LCD in 0.1% Triamcinolone cream.

Transcriptions Exercise 2_ch10


PATIENT NAME: Jenel Bordelan

HOSPITAL NO.: 5049247


SURGEON: Dr. John C. Howard, M.D.

By-lateral subdural hematomas.

By-lateral subdural hematomas.

By-lateral burr holes frontal and parietal for drainage of subdural hematomas.

General Endotracheal.

Sean Swellow, M.D.

The patient was brought into the operating room and after induction of general endotracheal anesthesia. The head was completely shaved, 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 carried down through the scalp, rainy clips where applied for homeostasis, self retaining retractor were placed, burr holes has been made with common perforator. Bleeding from bone was then controlled with bone wax. The left flexed of bone where taken out with a curette and the dura underneath was coagulated in a cruciate fashion. The dura was open widely and copuis amount of all the crankcase colored blood should form. This was irrigated copiously on both side and blake 7millimitter drain where advance under the scalp and into this hole and to this subdural space. Both wounds where close then with zero vicruse who close the gailio layer and 30 nylon to close the skin. Zero form dressing where applied and both drain where secured with 20 silk The patient was recovered from anesthesia and taken to the recovery room in satisfactory condition.


- formed when intial letters of each of the successive words or major parts of a compound term or of selected term or selected letters of words or phrase. Acronyms are pronounced as words. Initialisim are not.

• All caps letters of acronyms but when extended Do not Caps the word from w/c they formed unless its proper names.
E.g. AIDS, BiPaP
• Lower case form when acronyms become word
E.g. laser
Unusual Abbreviations
Eg. pO2, aVL, PhD
Plural Form
• Form the plural capitalized acronyms & initialisims by using lowercase s.
Eg: RBCs, WBCs
• Form the plural lowercase acronyms & initialisims by using lower case ‘s.
Eg: rbc’s, wbc’s
• Form the plural of single-letter abbreviations by using ‘s
E.g: X’s or serial K’s.
• No periods w/in or end of most abbreviations, including acronyms, abbreviated unit of measure, and brief forms.
• No periods w/ academic degrees and professional credentials
• Periods in lowercase drug-rel abv.
• No double period on lower case.
Brief forms
• Transcrib as is…if they are commonly used, but extend on HEADINGS, DIAGNOSIS, & OPERATIVE TITLES.
• No ending periods
Eg: phone-telephone, Pap smear – Papanicolaou smear
Unit of Measure
• Abbreviate if accopmpanied by numeral even dictated in full.
Eg: 2.5mg 3 g/dL , 5 cc
• Avoid separating numeral from its associated unit of measure.
• Never begin in lowercase letter such as pH.
• Sentence may begin w/ dictated abbreviation, acronym or brief form (except unit of measure)
Diagnoses & Operative Titles
• Write abbreviation or acronym in full if it is used in the
Eg. Admission, Discharge, Preoperative, Postoperative Diagnosis, Consultative Consultation, or Operative Title.
Accent Marks
• Omitted in MT w/c are not essential to communication.


– modifiers used to indicate the definiteness (the) or Indefiniteness (a,an) of the noun that follows. The used of articles varies. Sometimes article is required. Sometimes it is optional. Sometimes it should be omitted.
Required: We will do a CBC.
Optional: She was admitted to the ICU. Or She was admitted to ICU.


• Names of elements are NOT CAPITALIZED
• Symbols of chemical elements always include INITIAL CAPITAL LETTER.
• If second letter, use the LOWERCASE.
• NEVER used periods or other punctuation w/ chemical symbols.
E.g : barium – Ba calcium – Ca gadolinium – Gd


• When anatomic position is described in terms of clockface orientation, used o’clock
E.g: The incision was made at the 3 o’clock postion.
• Don’t used o’clock words if position is subdivided.
D: The cyst was found at the 2:30 o’clock position. T: The cyst was found at the 2:30 position.


• Avoid “contraction” exept in direct quotations.
E.g. The mother reported, “He’s been hysterical.”
• If possible EXTEND Abbreviation that contain contraction.
D: The patient OD’d on Valium. T: The patient overdosed on Valium.
D. Stool was guaiac’d. T: Guaiac test was done on the stool.


• Use Arabic or roman numeral for cranial nerve designation. Be consistent.


• When month, date & year are given in this sequence, set off the year by COMMA. Do not used Ordinals.
D: She was admitted on December 14th 2003 T: She was admitted on December 14, 2003.
• NO COMMA on military date or no year was given.
T: She was admitted in December 2001.
T: She was admitted on 14 December 2001.
• NO punctuation after year if date STAND alone.
T: ADMISSION DATE: April 3, 2000
• Use ordinals when day of month precedes the month us preceded by “THE, Do nor use commas.
• Do not use ordinals in month/day/year format.
T: the 4th of April 2001 not April 4th, 2001
Military Style
• Military style used – day precedes by month
• No ordinals in day/month/year format.
• Use numerals not common.
T: 4 April 2001
T: 4 Apr 2001
In Text
• Preferable to spell out dates used in the body of a report.
• Writing out the name of the month and in using four digits for the year.
T: The patient is previously seen on April 14, 2001.
• When month/day are dictated- as is. add the year only if you are certain.
D: The patient was last seen on April 4th. T: The patient was last seen on April 4, 2003.
• Date used repeatedly – expressed as numerals separated by virgules or hyphens as long as they clearly understood.
T: Electrolytes on April 23, 2001, revealed a sodium of 135, potassium 4.3, bicarbonate 25, chlorides 102. Repeated on 4/35 and again on 4/26. Electrolytes remained within normal limits.
End of line
• Avoid dividing between month and day.


• Described 1st, 2nd,3rd or 4th degree.
Eg. 1st degree burn
• Dropping hypen in adjective form.
Eg. 2nd –degree burn
• Write out degrees or use of degree sign (º).
Eg. The patient was able to straight leg raise to 40 degrees to 40º.
• Express w/ numerals except for zero.
• No space between degree symbol and temperature scale.
T: zero degrees 36 degrees 36ºC
• Use minus to indicate temperature below zero.
T: minus 48ºC
• If temperature scale (Celsius, Fahrenheit, Kelvin) or abbreviation (C,F,K) not dictated. It’s not necessary to insert it.


Abbreviation in diagnoses
• No abbreviation for diagnostic term in document section designating impression, admission diagnosis, discharge diagnosis, preoperative diagnosis, and postoperative diagnosis.
• Transcribed it as dictated if you cannot determine the meaning of a dictated abbreviation or acronym.
D: Operation. Left BK A T: Operation: Left below- knee amputation.
• Some descriptive terms rel to diagnosis may be abbreviated. Use abbreviation for units of measure.
Diagnosis: Laceration, 5 mm, Left abdomen.
Numbering diagnosis
• If plural form diagnoses if more than one listed. If one only diagnosis.
• It is preferable not to number one diagnosis even if a number is dictated. If there are several diagnoses, it is preferable to number them even if the numbers are not dictated.
E.g : DIAGNOSIS: Appendicitis
1. Appendicitis.
2. History of coronary artery bypass graft (CABG).
Psychiatric Diagnoses
• A multiaxial system is often used in diagnosis psychiatric patients:
Axis I: All psychiatric disorders.
Axis II: Personality disorders & Mental retardation.
Axis III: General medication condition.
Axis IV: Psychosocial and Environmental problems.
Axis V: Assessment of functioning, usually global assessment of functioning (GAF) scale.
• Dictated along w/ applicable diagnostic codes found in Diagnostic Statistical Manual of Mental Disorders
Axis I: 296.2 Major depressive disorder, single episode, severe without psychotic features.
305.0 Alcohol Abuse.
Axis II: 301.6 Dependent personality disorder.
Axis III: None.
Axis IV: Threat of job loss.
Axis V: GAF 53 (current)
Differential diagnosis
• When patient present w/in group of symptoms and diagnosis is unclear, the clinician may refer in medical report to the differential diagnosis in order to compare and contrast the clinical finding of each. Although it consists of two or more possible diagnoses, the term differential diagnosis takes a singular verb.
T: The differential diagnosis was….
• Do not transcribed “same” when dictated for the discharge diagnosis - repeat diagnosis in full.
D: Admission diagnosis: Left testicular hernia.
Discharge diagnosis: Same.
T: ADMISSION DIAGNOSIS: Left testicular hernia.
DISCHARGE DIAGNOSIS: Left testicular hernia.
• Beware of similar incomplete statements w/in names of operations and transcribed them in full.
D: Operation performed : Repair of same.
T: OPERATION PERFORMED: Repair of left testicular hernia.


• Exponents are generally superscripted, but if not available, use appropriate abbreviation (cu or sq) instead.
10 5 or 10 to the 5th 4 cm2 or 4 sq cm


• Use followup for the noun and adjective form (follow-up is an alternative). The two word follow up is a verb.
The patient did not return for followup (Noun)
In followup visits, she seem to improve (Adj.)
We will follow up with the regular visits (Verb)


• Use numerals for fractional measurements preceding noun.
E.g. A ¾ -pound tumor was removed.
• Use HYPEN to join fraction & unit of measure. Place HYPEN in between numerator and denominator when neither contains a hyphen.
E.g. one-fourth empty two-thirds full.
• HYPENATED fractions when they are written out and use as adjectives; do not hyphenate those written out and used as an adjectives; do not hyphenate those written out and used as nouns.
E.g. one-half normal saline one third of the calf
• Spell out fraction measurements that are LESS THEN ONE when they do not precede a noun.
E.g. The tumor weighed three quarters of a pound.


5-French catheter #5 French catheter catheter, size 5


• Preferred abbreviation is “g”. Space in between
• No final period
E.g. 4 g is preferred to 4 gm


• CAPITALIZED the “G” in Gram stain
E.g. We ordered a Gram stain stat.
• LOWERCASE gram-negative and gram positive
Eg. The specimen was gram-negative.


• Capitalized GENUS names and their abbreviated forms when they are accompanied by a species name.
• Always LOWERCASE the SPECIES name.
Eg: Haemophilus influenzae Escherichia coli
• LOWERCASE genus names used in plural & adjective forms and when used in the vernacular, for example, when they stand alone (w/o species name).
Eg: staphylococcus group B streptococcus
• LOWERCASE temrs formed with the suffixes –osis and –iosis indicate disease caused by a particular class of infectious agents or types of infection.
Eg: amebiasis dermatphytosis
• Genus name may be abbreviated as a SINGLE letter w/o a period . A longer abbv may be used to avoid confusion.
Eg: S aureus or Staph aureus
• Do not abbreviate species name even if the genus name is abbreviated.
E.g. D: H flu T: H influenza
• Do not used italics for genus and species names.


• Health care – Noun
• Healthcare – Adjective


• Substances that dissociate into positive and negative ions in solution. It generally include sodium, potassium, chloride, and total CO2 or Bicarbonate. Though not technically electrolytes, BUN, creatinine and glucose are also part of a chemistry profile and often dictated in the same breath.

LABORATORY DATA: Electrolytes: Sodium 139, potassium 4.6, chloride 106, bicarb 28, BUN 15, creatinine 0.9, glucose 132. White count 5.9, hemoglobin 14.6, hematocrit 43.1.
Hemoglobin & Hematocrit
• Often dictated as H & H or H over H – Translate the abbreviation into their respective terms.
D: H and H 11.8 and 35.3.
T: Hemoglobin 11.8 and hematocrit 35.3.
Percentage Values
• Use the expression dictated
E.g. MCHC 34% or MCHC 0.34 or MCHC 34, polys 58% or polys 0.58 or polys 58
• Do not convert ore remove unless the forms are mixed, then make them consistent.
Specific Gravity
• Express w/ 4 digits and a decimal point place between 1st and 2nd digits. Do not drop the final zero.
Tumor Cell Markers
• Express w/ capital letters and Arabic numerals, w/o spaces or punctuation between letter and number.
E.g. CD4
• Term evolved from urine analysis, which is now archaic – Edit to URINALYSIS. Used abbrv UA only if dictated.
D: Urine analysis showed T: Urinalysis showed


Awkwardly Words – Edit some awkwardly created verbs. (EDITORS PROBLEM)
D: Stool was guaiac’d T: Stool guaiac test was done.
D: The baby was de-lee’d on the abdomen. T: The baby was rotated on the abdomen using DeLee.
Back Formation -Used only widely acceptable words. Avoid absurb back formations or onces that will be confusing to the reader.
E.g. dehiscence to dehisce diagnosis to diagnose torsion to torse
Coined terms – Nonofficial, nonstandard terms. Avoid as much as possible.
E.g. We lased the tattoo in one session.
Jargon – Used and fully understood only by members of a particular craft, trade or profession.
D: urines D:urines
T: urine samples T: ____ leave blank and flag for alternative description)
Slang – avoid slang terms and phrases
Dexamethasone not dex appendectomy not appy


– commonly used in English comm & need not be translated.
- used periods within and end as preferred style, although it is acceptable to drop the periods.
- used comma BEFORE & AFTER the abbreviation (e.g., et al., etc., i.e., viz.,)
D: Her symptoms come on with exertion, e.g., when climbing stairs or running.
D: Her symptoms come on with exertion, for example, when climbing stairs or running.


Horizontal List or Run-on
• Enclose Arabic numerals in parentheses to delineate the items in the list.
• Preferred style is to used commas at the end of each item in the horizontal list.
• Use semicolons instead of commas if an item contains internal commas.
• Do not capitalize items separated by commas or semicolons.

Her past history includes (1) diabetes mellitus, (2) cholecystitis, and (3) hiatal hernia.
Her past history includes (1) diabetes mellitus, which is controlled with oral agents; (2) cholecystitis, resolved; and (3) hiatal hernia.

• Other style choice is to use a capital letter to start each item in the list and use a period at the end of each item.
Her past history includes (1) Diabetes mellitus. (2) Cholecystitis. (3) Hiatal hernia.

• Colon may be used in place of the verb to introduce either type of list.
Past history: (1) diabetes mellitus, (2) cholecystitis, (3) hiatal hernia.
Past history: (1) Diabetes mellitus. (2) Cholecystitis. (3) Hiatal hernia.

Vertical list or Displayed
• Used block style, with all entries aligned at the left margin.
• If numbered, follow each Arabic numeral by a period and then one character space; do not place numbers in parentheses.
• Capitalize the 1st letter of each entry, whether or not numbered (but it is preferable to number the items if there is more than one).
• Place a period at the end of each entry in the list.
1. Diabetes mellitus.
2. Cholecystitis.
3. Hiatal hernia.
Type 2 diabetes mellitus.

• If entries in the list are names or dates, no period is used.
Mabel Smith, MD
Harry Jones, MD

Hanging indentation
• Alternative form for displayed lists.
• Work best with display lists that are presented in sentence form.
• used Arabic numerals. Begin the 1st line of each item (the number) at the left margin and indent subsequent lines.
1. Hypertension. Blood pressures continue to run high. Will start the patient on Lotensin 20 mg p.o. daily, which may be increased to 40 mg next month if her numbers do not come down.
2. Diabetes. Continue the glyburide, which the patient is currently taking twice a day in a divided doses. May consider reducing this if blood sugars stay within normal or if hypoglycemia becomes a problem. Continue the Actos begun last month.
3. Return in 4 weeks for followup. Patient instructed in recording blood pressure readings. She will also monitor her blood glucose twice a day.



a.c. before meals or food b.i.d. twice daily h.s. at bedtime
p.c. after meals p.o. by mouth p.r.n. as needed
O.D. right eye O.S. left eye O.U. each eye
meg microgram(s) mg milligram(s) mEq milliequivalent(s)
mL milliliter(s) q.o.d. every other day q.h. every hour
q. 4h. every four hours q. 8h every eight hours q.i.d. four times a day
q.o.d. every other day t.i.d. three times a day


• Numerals, or figures, stand out from the surrounding text and serve a functional purpose in medical reports, where they should be used almost exclusively as opposed to spelled-out numbers.
She was seen in the emergency room 1 hour after the accident.
He tried 3 different medications without success.
The specimen weighed less than 2 pounds.

Adjacent Numbers
• when two numbers are consecutive, spell out one of them to avoid confusion.

The patient was instructed to drink eight 8-ounce glasses of GoLYTELY before bedtime.
Discharge Medication: Os-Cal 500 one daily.
two 8-inch drains

• Use a comma to separate adjacent unrelated numerals if neither can be readily expressed in words and the sentence cannot be readily reworded.

In March 2002, 2038 patients were seen in the emergency room.

• Spell out or use numerals for common fractions. Use the dictation style as guide.

An hour and a half before presentation, the patient slipped and fell.
or Approximately 1-1/2 hurs before presentation…. (if dictated “one and a half hours” or “one and one-half hours”)
The glass was two-thirds full or The glass was 2/3 full.
7/8-inch wound

Beginning of A Sentence
• Spell out numbers that begin a sentence, or recast the sentence.

D: Fourteen days ago she started having severe cramping.
T: Fourteen days ago she started having severe cramping.
or She started having severe cramping 14 days ago.

• An exception of this exception: A complete year that begins a sentence need not be spelled out.
2005 will mark our hospital’s 100th anniversary.
Note: Although it’s acceptable to begin a sentence with a year, it is better to recast the sentence if possible.
D: 1995 was when her symptoms began.
T: Her symptoms began in 1995.

• is always spelled out when it stands alone.
The patient had zero response to the treatment.
Her symptoms usually appear when the outside temperature drops below zero.

Gravida 1, para 0 0ºF

Numbers Commonly Spelled Out
• Common or accepted usage may dictate that a word be spelled out. For example, use of a numeral may cause confusion by placing emphasis and implying a precise quantity where none is intended.
His symptoms went from one extreme to the other.

Nonspecific Numbers
• Spell out nonspecific (indefinite) numeric expressions.
She described hundreds of symptoms (not 100s)
Several thousand people were tested.

• Ordinal numbers are used to indicate order or position in a series rather than quantity. Ordinals are commonly spelled out, especially when the series goes no higher than 10 items. However, as with all numbers in medical reports, AAMT recommends using numerals: 1st, 2nd, 3rd, 4th, etc.
• Do not use a period with ordinal numbers.
3rd rib (or third) 5th finger (or fifth)
She is to return for her 3rd (or third) visit in 2 days.
She was in her 9th (or ninth) month of pregnancy.
His return visits are scheduled for the 15th and 25th of next month.
The 4th cranial nerve.

use hyphens which numbers are used with words as compound modifiers preceding nouns.
E.g. 5-cm incision
3 x 2-cm mass
13-year 2-month old girl
use hyphens to join some compound nouns with numbers as prefixes. Check appropriate references for specific terms.
E.g. 2-D
use hyphens in compound numbers from 21 to 99 when they are written out. (Note: The only time they should be written out is at the beginning of a sentence.)
E.g. thirty-four one hundred fifty-three

use a comma to separate groups of three numerals in numbers of 5 digits or more, but omit the commas if decimals are used. The comma in 4-digit numerals may be omitted.
E.g. Platelet count was 354,000.
White count was 7100 or …7,100.

do not place commas between words expressing a number.
E.g. four hundred forty-eight
Not four hundred, forty-eight

• Use ‘s to form the plural of single-digit numerals.
E.g. 4 x 4’s
• Add s without an apostrophe to formt he plural of multiple-digit numbers, including years.
E.g. She is in her 20s
She was born in the 1940s.

Multiple Digits
• when dictated in a form such as “four point two thousand” or “five point eight million”, numerals may be transcribed in one of two ways:
(1) 4.2 thousand or (2) 4200;5.8 million or 5,800,000.

Proper Numbers
• Use words or figures for numbers in proper names, according to the entity’s preference.
E.g. 20th Century Insurance
Three Dollar Café

At End of Line
• when possible, do not separate numerals from the terms they accompany. Do not allow a numeral to end on one line and its accompany term to begin the next.
………………………………..grade 2. Not ………………………grade 2.

No, #
• Abbreviation and symbols for number. Note that the abbreviation capitalizes the initial letter and has an ending period: No. When the symbol # is used, the numeral follows it with no space between.
E.g. No. 4 blade
#4 blade

Position or Rank
• use the abbreviation or symbol with a figure to indicate position or rank.
e.g. He is No. 4 on the appointment list.
or He is #4 on the appointment list.

Model and Serial Numbers
• use the symbol with Arabic numerals.
E.g. model #8546 serial #185043

Sizes of Instruments or Sutures
• Do not use the abbreviation or symbol if “number” is not dictated. Either is acceptable (with the symbol preferred to the abbreviation) if “number” is dictated. Be consistent.

E.g. 5-French catheter, #5-French catheter, No. 5-French catheter
3-0 Vicryl, #3-0 Vicryl, No. 3-0 Vicryl

Street Addresses
• do not use the abbreviation or symbol before the number in street addresses.
E.g. 166 Wallingford Avenue Not No. 166 Wallingford Avenue
Not #166 Wallingford Avenue

• Use the numeral for the ages mentioned in the dictation.
E.g. 7-year-old child 15 years 3 month old

Alphanumeric Terms
• Use the numeral for a alphanumeric terms.
E.g. G6P5 L4-5

Clock Referents
• use the numeral for clock referents.
E.g. The lesion was seen in the left breast at the 8 o’clock position.
The incision was made from the 7:30 to 9:30 position.
Decade References
• use the numeral for decade references
E.g. The patient’s father is in his 80s.
The patient hasn’t been to a dentist since the ‘80s.

EKG Leads
• use the numeral for decimals.
E.g. V1 through V6
leads I, II, and III

• Use the numeral for eponyms.
E.g. Apgar scores were 9 and 9.
Clark Level II melanoma
Billroth II anastomosis
Hunt and Hess neurological grade 3
LeFort I maxillary reconstruction


GPA System
• GPA is abbreviation for gravid, para, abortus. Accompanied by Arabic numerals, G,P, and A (or Ab) describe the patient’s obstetric history.

• Use arabic numerals. Roman numerals are not appropriate.
G gravid (number of pregnancies)
P para(number of births of viable offspring)
A or Ab abortus (abortions)
Nulligravida gravid O – no pregnancies
Primigravida gravid 1, G1 1 pregnancy
Secundigravida gravid 2, G2 2 pregnancy
Nullipara para O no deliveries of viable offspring

• separate GPA sections by commas. Either the abbreviated or the spelled out form may be used, whichever is dictated.
E.g. Obstetric history: G4,P3 and AL
or Obstetric history: gravid 4, para 3, abortus 1.

TPAL System
• system use to described obstetric history of a patient.
T term infants
P Premature infants
A Abortions
L living children
Separate TPAL number by hyphens.

E.g. Obstetric history: 4-2-2-4.
• TPAL numbers need not be spelled out unless dictated that way, for example
E.g. Obstetric history: 4 term infants, 2 premature infants, 2 abortions, 4 living children.
• Sometimes, GPA terminology is combined with TPAL terminology.
E.g. The patient is gravid 3, 3-0-0-3, or gravid 3, para 3-0-0-3 or G3, P3-0-0-3
or gravid 3-0-0-3

Cesarean Section
• not Cesarean, caesarean, or Caesarean.
Brief form is C-section, but do not use it unless it is dictated, and even then do not use it in the operative title section of the operative reports or discharge summaries.


• Preposition. Do not follow by of.

E.g. He fell off the roof. NOT He fell off of the roof.


• note that percent is a single word. Do not use the abbreviation pet. Except in tables. Instead, use % or percent.
E.g. 50% or fifty percent not 50 pet.

• use the symbol % after a numeral. Do not space between the numeral and the symbol.
E.g. 13% monos, 1% bands
She has had a 10% increase in weight since her last visit.
MCHC 34%
10% solution
• when the number is written out, as at the beginning of a sentence, write out percent.
E.g. Fifty percent of the patients were given a placebo.

• in a range of values, repeat % (or percent) with each quantity.
E.g. Values ranged from 13% to 13% NOT Values ranged from 13 to 18%.
Fifty percent to eighty percent… NOT Fifty to eighty percent.

• Percent of takes a singular verb when the word following of is singular, a plural verb when the word following of is plural.

E.g. Ninety percent of the body was burned.
Forty percent of the patients were in the control group.

Less than 1 percent
• When the amount is less then 1 percent, place a zero before the decimal. 0.5% not .5%


• express by a whole number or a whole number followed by a decimal point and one or two digits. A whole number may be followed by a decimal point and a 0 to demonstrate that the value following the decimal point has not been mistakenly deleted.

E.g. pH 7.55 pH 7.4 pH 7.0

• do not express other than with a lowercase p and capital H. if the term begins a sentence, precede it by The or recast the sentence.

E.g. D: pH was 6.47
T: The pH was 6.47


• the expanded form, prothrombin time, is preferable, but if the short form is used it should be written as two words: pro time.

• Use numerals. It is acceptable to use a hyphen between the limits of a range if the following five conditions are met.
1. The phrases “from…to,” “from…through,” “between…and” are not used.
2. Decimals and/or commas do not appear in the numeric values.
3. Neither value contains four or more digits.
4. Neither value is a negative.
5. Neither value is accompanied by a symbol.

• when all five conditions are met, a hyphen may be used. (To may be used instead, even when the conditions are met.)
E.g. Our new office hours will be 1-4 p.m. Tuesday and Thursday.
Systolic blood pressures were in the 150-180 range.
BP was 120-130 over 80-90.
8-12 wbc or 8 to 12 wbc.


• when any one of the five above conditions is not met, use to (or other appropriate wording) in place of a hyphen.
E.g. 3+ to 4+ edema 3-4+ edema
reflexes 2 +/4 to 3+/4
$4 to $5 million
-25 to +48
Weight fluctuated between 120 and 130 pounds.
Platelet counts were 120,000 to 160,000.
• do not use a colon between the limits of a range. Colons are used to express ratios, not ranges.
E.g. 80-125 NOT 80:125


• Express the values with numerals separated by a colon.
• do not replace the colon with a virgule, dash, hyphen, or other mark.
E.g. Mycoplasma 1:2
cold agglutinins 1:4
Zolyse 1:10,000
Xylocaine with epinephrine 1:200,000

• Use to or a hyphen instead of a colon when the expression includes words or letters instead of values.


• Nine-digit number assigned by the Social security Adminstration.
E.g. 099-12-3456


• Capitalize the name of languages, peoples, races, religions, and political parties.
E.g. Caucasian Chinese Filipino
Methodist Republican
• Color designations of race and ethnicity are usually not capitalized.
E.g. 75-year-old black woman
85-year-old white man
• Sexual preferences or orientation are not capitalized.
E.g. gay heterosexual lesbian
• it is no longer necessary (or preferred) to hyphenate designations of Americans who are identified by their ethnicity, race, or nationality of origin, either in the noun form or the adjectival form.
E.g. elderly Asian American man


• Express with four digits and a decimal point placed between the first and second digits. Do not drop the final zero.
E.g. D: specific gravity ten twenty
T: specific gravity 1.020


Stage and Grade
• lowercase stage and grade.
• Lowercase type when used as an adjective. Use Arabic or roman numerals or capital letters, depending in type referred to.
E.g. type 2 diabetes mellitus
type II hyperlipidemia
type A personality
Cancer Stage and Grade
• use roman numerals for cancer tages. For subdivisions of cancer stages. For subdivisions of cancer stages, add capital letters on the line and Arabic suffixes without internal spaces or hyphens.
E.g stage 0 stage I, stage IA stage stage II, stage II3
• Used Arabic numerals for grade.
E.g. grade 1 grade 2 grade 3


• brief form for the Latin statim meaning immediately. There is no need to capitalize it or to follow it with a period.
E.g. We ordered a stat EKG and serial cardiac enzymes.


• Latin phrase meaning state or condition after or following. Do not italicize. Do not hyphenate.
• When status post is use, place a space between post and the word or phrase following it.
E.g. status post hysterectomy
Left 5th toe gangrene, status post forefoot amputation.


• use superscripts only if they can be placed appropriately and in reduced size, and if technological limitations do not delete them; otherwise, us an alternative, on-the-line form.
E.g. 33 sg m


USP System
• The United States Phamacopeia system sizes, among other things, steel sutures and sutures of other materials. The sizes range from 11-0 (smallest) to 7 (largest). Place the symbol # before the size if “number” is dictated.
E.g. 1-0 nylon or 0 nylon 2-0 nylon NOT 00 nylon #7 cotton NOT 0000000 cotton
D: 3 and 4 oh silk T: 3-0 and 4-0 silk

Brown and Sharp Gauge (B&S Guage)
• System for sizing stainless steel sutures. Use whole Arabic numerals ranging from 40 (smallest) to 20 (largest)


• Avoid as much as possible because it reduces readability. Use regular type instead, or if type must be distinguished from regular type, use italics or boldface.
• If underlining must be used, underline the full phrase, including spaces and punctuation, except that final punctuation.


Metric System
• Use the abbreviations only when a numeric quantity precedes the unit of measure. DO not add an s to indicate plural form.
E.g. 10 cm 5 mm

• Do not capitalize most metric units of measure or their abbreviations. Learn the obvious exceptions and consult appropriate references for guidance.
E.g. dB – decibel Hz – hertz L – liter

• Use the decimal form with metric units of measure even when dictated as fractions, unless they are not easily converted
E.g. D: four and a half millimeters T: 4.5 mm not 41.2 mm
D: four and a third millimeters T: 4-1/3 mm

Non-Metric System
• Spell out common nonmetric units of measure (ounce, pound, inch, foot, yard, mile, etc.) to express weight, depth, distance, height, length, and width, except in tables. Do not use an apostrophe or quotation marks to indicate feet or inches, respectively (except in tables).

E.g. 4 pounds 5 ounces 14 inches 5 feet
5 feet 3 inches NOT 5’3” NOT 5 ft. 3 in.

• Do not abbreviate most nonmetric units of measure, except in tables. Use the same abbreviation for both singular and plural forms; do not add s.
E.g. 5 in. (use in, only in a table)

• do not use comma or other punctuation between units of the same dimension.
E.g. The infant weighed 5 pounds 3 ounces.
He is 5 feet 4 inches tall.

• Use hyphen to join a numbr and a unit of measure when they are used as an adjective preceding a noun.
E.g. 4.5-mm incision 8-inch wound 8-pound 5-ounce baby girl

• Avoid separating a numeral from its accompanying unit of measure (abbreviated or not) at the end of a line. If technology allows, use a required space, coded space, or nonbreaking space between them to assure that the numerals move to the next line along with the abbreviation.
E.g. …………………………………..5 cm
not …………………………….5
*Do not repeat units of measure in a related series unless their absence will confuse the reader.
E.g. The daily dose were 140, 135, and 58 mL, respectively.
4 x 5-cm mass

X, x

• Use only with numerals. Use a lowercase x in expressions of area and volume, as a multiplication symbol, and when it takes the place of the word times. A capital X is generally use to express magnification.

E.g. X30 magnification

x meaning By (Dimensions)
• Use a lowercase x to express by in dimensions. Use a space before and after the x.

E.g. 13 x 2 cm

x meaning For
• When the word “times” is dictated and can be translated as for, it should be transcribed as for rather than using times or x.
E.g. D: The patient was given antibiotics to take times 2 weeks.
T: The patient was given antibiotics to take for 2 weeks.

x meaning Times
• When the word “times” is dictated and means the number of times a thing was done, the letter x can be used.
• To keep this expression together and easily read as a unit, do not place a space after the x.

E.g. D: Blood cultures were negative times 3.
T: Blood cultures were negative x3.

• Use the symbol x meaning times only when the x precedes a numeral.

E.g. D: Demerol was administered 3 times.
T: Demerol was administered 3 times, not…..3x.


• Refers both to the radiologic process and to the radiation particles. Whether used as a noun, verb, or adjective, lowercase and hyphenate.

E.g. His x-ray was not in the jacket. (noun)
He was x-rayed yesterday. (verb)
His x-ray films have been lost. (adjective)

• Capitalized x-ray only when it is the first word in a sentence.
E.g. X-ray films showed….
• Avoid using the prefix re- with x-ray. Edit instead.
E.g. x-ray again preferred to re-x-ray not rex-ray