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Transcription Essay

564 words - 3 pages

Patient #1

Subject is doing really well, she’s in for just a check up on a chronic problem. She reports she’s doing really well, she needs her cholesterol checked. The rash on her groin has completely cleared up on Licon. Objective noted no acute stress, vitals noted, blood pressure looks pretty good, noted clear skin trauma dry, extremities in a remarkable movement which i think is congruent, labs are updating including a CMP and lipid panel and I got a fasting blood sugar which was 118; so subsequent A1C was drawn and that was found to be 6.1. Unfortunately she had gone ahead and left prior to getting the A1C. Assessment: hypertension, hyperlipidemia, new onset boarder line diabetes. Plan: need to contact her about this finding, and discuss the implication, we’ll adjust medicines as ...view middle of the document...

I would like to wait to see whether its just the season or not. Wait until follow-up.

Patient #3

Right totally arthroplasty wound, multifactorial...Crohn’s Disease.
Mr. Fields returns today in follow-up period, he has been doing well on oral avelox following removal of his right knee arthroplasty for his suspected infection period; he has had no positive cultures for any likely pathogens from his operative cultures. He was discharged on avelox with the suspicion that his non-healing wounds are more likely related to the imuran therapy he’s been on before his Crohn’s Disease. He is no longer taking imuran and his right knee appears to be healing nicely.
Exam appears to be no stress period, chest is clear via cardiograph, regular rhythm period, right knee wound appears to be granulating in. There is no disposable drainage, there is a bit of serous drainage on the dressing
Impressions: improvement in the non-healing wound. I believe that he has no evidence to suggest infection at this time.
Plan: #1) he will continue with the avelox to complete his prescription, approximately another 2 weeks. Then he will discontinue #2) further evaluation and treatment based upon Dr. Elkis’s assessment and plan. At some point he needs the replacement of his knee. However, this will be delayed until he has been adequately healed I suspect. Will see him back again on as needed basis.

Patient #4
Subject is coming in today for re-evaluation of her left shoulder. She recently had a left shoulder CT as well as a left shoulder ultrasound demonstrating #1) rotator cuff of left shoulder shows full ..of anterior muscle ...notice repair. #2) biceps tendinosis, tendonitis of left shoulder. #3).....
She notes her symptoms as unchanged since her last visit and following these imaging studies.
Medical update 4 month review will be incorporated in her chart.

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