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%
Thursday, May 14, 2009
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%
Thursday, April 23, 2009
OB 4 DISCHARGE SUMMARY
ADMITTING DIAGNOSIS: Cystocele with urinary incontinence.
FINAL DIAGNOSIS: Cystocele with urinary incontinence.
PROCEDURE: Anterior repair.
COMPLICATIONS: None
HISTORY: This is a 65-year-old woman who had had a previous hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.
Physical examination was unremarkable except for the cycstocele.
Lab work, including a panel, CBC, EKG, and chest x-ray, was essentially within normal limits. Following surgery the patient has done well. The vaginal pack was removed this date and the Foley catheter. She will be checked for residual. IF the residual is over 150 cc, the Foley will be replaced and the patient taught to use the catheter plug, and she will be discharged. She will be seen in the office in approximately one week for follow-up.
FINAL DIAGNOSIS: Cystocele with urinary incontinence.
PROCEDURE: Anterior repair.
COMPLICATIONS: None
HISTORY: This is a 65-year-old woman who had had a previous hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.
Physical examination was unremarkable except for the cycstocele.
Lab work, including a panel, CBC, EKG, and chest x-ray, was essentially within normal limits. Following surgery the patient has done well. The vaginal pack was removed this date and the Foley catheter. She will be checked for residual. IF the residual is over 150 cc, the Foley will be replaced and the patient taught to use the catheter plug, and she will be discharged. She will be seen in the office in approximately one week for follow-up.
Opta 7 HISTORY AND PHYSICAL EXAMINATION
HISTORY AND PHYSICAL EXAMINATION
PREOPERATIVE DIAGNOSIS:
1. Cataract of left eye.
2. Pseudophakia of the right eye.
3. Dermatomyositis.
4. Rheumatoid arthritis.
HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function. She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye. She has had dry eyes and uses artificial tears frequently. She had had ectropion repair of the right lower lid. She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this. She is presently taking Persantine twice daily and Inderal 40 mg twice daily. She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.
PHYSICAL FINDINGS:
VITAL SIGNS: Blood pressure 110/80, pulse 76 and regular.
HEENT: Eyes; Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left. Pupils and extraocular motility were normal. Intraocular pressures where 18. Slit-lamp exam showed the eyelids in good position with weakness of the orbicularis and facial muscles. There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left. Fundus examination in each eye was normal.
EARS, NOSE, AND THROAT: Tympanic membranes are normal. The oral cavity showed dentures in place, and the pharynx had no lesions.
NECK: The neck showed a slight right carotid bruit, and the left was normal.
CHEST: The chest was clear to auscultation.
HEART: Heart had a regular sinus rhythm without murmur.
EXTREMITIES: Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.
PLAN: Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient. The risks of the procedure, including possible loss of the eye, were discussed.
PREOPERATIVE DIAGNOSIS:
1. Cataract of left eye.
2. Pseudophakia of the right eye.
3. Dermatomyositis.
4. Rheumatoid arthritis.
HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function. She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye. She has had dry eyes and uses artificial tears frequently. She had had ectropion repair of the right lower lid. She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this. She is presently taking Persantine twice daily and Inderal 40 mg twice daily. She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.
PHYSICAL FINDINGS:
VITAL SIGNS: Blood pressure 110/80, pulse 76 and regular.
HEENT: Eyes; Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left. Pupils and extraocular motility were normal. Intraocular pressures where 18. Slit-lamp exam showed the eyelids in good position with weakness of the orbicularis and facial muscles. There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left. Fundus examination in each eye was normal.
EARS, NOSE, AND THROAT: Tympanic membranes are normal. The oral cavity showed dentures in place, and the pharynx had no lesions.
NECK: The neck showed a slight right carotid bruit, and the left was normal.
CHEST: The chest was clear to auscultation.
HEART: Heart had a regular sinus rhythm without murmur.
EXTREMITIES: Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.
PLAN: Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient. The risks of the procedure, including possible loss of the eye, were discussed.
Pulmo 5 EMERGENCY ROOM REPORT
EMERGENCY ROOM REPORT
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.
PHYSICAL EXAMINATION
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.
EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.
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.
PHYSICAL EXAMINATION
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.
EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.
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