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#13890 - 10/18/11 12:50 PM feed back please any info on proofread for errors
KLobe Offline
Gabber

Registered: 07/10/11
Posts: 13
Loc: Florida
HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT: Herniated cervical disc.

HISTORY OF PRESENT ILLNESS: This is a 35-year-old white female with cervical pains. She was involved in a car accident 8 years prior to this with no history of neck pain and has developed progressive neck pain since the end of the last year. She was initially treated with physical therapy support and medication with only minor relief. More recently, the pain has been increasing, radiates from the base of the occipital, down to the neck and into both arms. The pain was originally intermittent but has been increasing with time. She originally has intermittent paresthesia which have been increasing to the point where she now claims that she have a large amount of paresthesia in the entire right arm and of the left index and long fingers. She claims to have some weakness in the right arm and has compared to the left. She has no bowel or bladder symptomatology, MRI scan has reportedly shown central herniation at C4 5 and C5 6.

PAST MEDICAL HISTORY: Negative for seizures, diabetes, hypertension, heart disease, lung disease, asthma, chest pain, shortness of breath, peptic ulcer disease, hepatitis, liver disease or kidney diseases. Diagnostic and operative arthroscopy of the right knee in 1984. Right knee surgery, 1985 with transfer of the tibial tubercular. Hysterectomy in 1983, tubal ligation in 1979.

SOCIAL HISTORY: She is a house wife and is married. Smoking half a pack per day. Alcohol none.

FAMILY HISTORY: Her father is deceased secondary to lung cancer. Her mother is deceased secondary to heart disease. Her sister has diabetes and two brothers who have cancer. One with lung cancer and the other with throat cancer.

ALLERGIES: Penicillin which causes hives and erythromycin, which causes nausea, vomiting and hives.

MEDICATIONS: Percodan 1-2 p.o. today and Flexeril 1 pill every 6 hours.

REVIEW OF SYSTEM: Noncontributory.

GENERAL: Appears this is a well developed well nourished white female, who is status post cervical Milo gram. Today she has a pulse of 76, blood pressure of 110/80 temperature is 98.7 respiration are 20 and weight is 156 pounds.

HEENT: Atraumatic and normal symphonic.

PUPILS: Are equal round reactive to light and accommodation. Extra auricular movement are in tact. The Sclera are white and conjunctivae are pink.

PHRAYNX: Is without lesion or exudates.

NECK: There is a paraspinal muscle spasm in the cervical region along the tenderness. This is diffused from base of the occipital C7. She has decreased range of motion secondary to pain.

LUNGS: Clear to auscultation both internally and posterally.

BREASTS: Are no masses legions exited there is a welled healed surgical scar above the right nipple.

HEART: Regular rate and rhythm without rubs gallops or murmurs.

SPINE: Non tender in the thoracic and upper regions.

ABDOMEN: Bowel sounds are positive. Soft and non tender.

RECTUM: Differed as the patient is 35- years of age.

NEUROLOGICAL: The patient claims to have a marked decrease in sensation from the right shoulder to right finger tips diffusely. She does not respond to pinch or to sharp pain. She has decreased sensation to left index and long fingers. The motor strength is 5/5 for the deltoid, biceps, triceps, rest flexors, rest extensors and interensics for both the right and left although there is some decrease on the right which appears to be secondary to pain. The lower extremities have 5/5 muscle strengths for all motor groups there is no calf pain there is a 2+ pulse for the radial to status pedis and posterior tibial pulses. The deep tendon reflexes are 2+ for biceps, triceps, brachioradialis, knee flexion and knee extension.

IMPRESSION: Herniated cervical disc.

PLAN: Myelogram today and anterior cervical fusion tomorrow.

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#13903 - 10/18/11 08:41 PM Re: feed back please any info on proofread for errors [Re: KLobe]
MTTerri Offline
Gabber

Registered: 09/18/11
Posts: 12
Loc: Florida
I sent you a private message.

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#14002 - 10/21/11 01:44 PM Re: feed back please any info on proofread for errors [Re: MTTerri]
KLobe Offline
Gabber

Registered: 07/10/11
Posts: 13
Loc: Florida
Hi Terri,

Im not sure I submitted my reply back to you correctly. I don't see it. I am still interested in hearing back from you on errors with grammar and med word. These are practice reports. All feedback will be greatly appriciated.
Thanks,
Karen

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#14008 - 10/21/11 04:06 PM Re: feed back please any info on proofread for errors [Re: KLobe]
MTTerri Offline
Gabber

Registered: 09/18/11
Posts: 12
Loc: Florida
Originally Posted By: KLobe
HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT: Herniated cervical disk.

HISTORY OF PRESENT ILLNESS: This is a 35-year-old white female with cervical pains. She was involved in a car accident 8 years prior to this with no history of neck pain and has developed progressive neck pain since the end of the last year. She was initially treated with physical therapy support and medication with only minor relief. More recently, the pain has been increasing, radiates from the base of the occiput down to the neck and into both arms. The pain was originally intermittent but has been increasing with time. She originally had intermittent paresthesias which have been increasing to the point where she now claims that she has a large amount of paresthesia in the entire right arm and of the left index and long finger. She claims to have some weakness in the right arm as compared to the left. She has no bowel or bladder symptomatology. MRI scan has reportedly shown central herniation at C4-5 and C5-6.

PAST MEDICAL HISTORY: Negative for seizures, diabetes, hypertension, heart disease, lung disease, asthma, chest pain, shortness of breath, peptic ulcer disease, hepatitis, liver disease, or kidney diseases.

PAST SURGICAL HISTORY: Diagnostic and operative arthroscopy of the right knee in 1984. Right knee surgery, 1985, with transfer of the tibial tubercle. Hysterectomy in 1983. Tubal ligation in 1979.

SOCIAL HISTORY: She is a housewife and is married. Smoking half a pack per day. Alcohol none.

FAMILY HISTORY: Her father is deceased secondary to lung cancer. Her mother is deceased secondary to heart disease. Her sister has diabetes and two brothers who have cancer, one with lung cancer and the other with throat cancer.

ALLERGIES: Penicillin, which causes hives, and erythromycin, which causes nausea, vomiting and hives.

MEDICATIONS: Percodan 1-2 p.o. today and Flexeril 1 pill every 6 hours.

REVIEW OF SYSTEM: Noncontributory.

PHYSICAL EXAMINATION:
GENERAL: Appears this is a well-developed, well-nourished, white female who is status post cervical myelogram.

VITAL SIGNS: Today she has a pulse of 76, blood pressure of 110/80. Temperature is 98.7. Respirations are 20, and weight is 156 pounds.

HEENT: Atraumatic and normocephalic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact. The sclerae are white and conjunctivae are pink. Pharynx is without lesion or exudates.

NECK: There is a paraspinal muscle spasm in the cervical region along with tenderness. This is diffuse from base of the occipital C7. She has decreased range of motion secondary to pain.

LUNGS: Clear to auscultation both anteriorly and posteriorly.

BREASTS: No masses or lesions elicited. There is a well-healed surgical scar above the right nipple.

HEART: Regular rate and rhythm without rubs, gallops, or murmurs.

SPINE: Nontender in the thoracic and upper regions.

ABDOMEN: Bowel sounds are positive. Soft and nontender.

RECTUM: Deferred as the patient is 35 years of age.

NEUROLOGICAL: The patient claims to have a marked decrease in sensation from the right shoulder to right fingertips diffusely. She does not respond to pinch or to sharp pain. She has decreased sensation to left index and long finger. The motor strength is 5/5 for the deltoid, biceps, triceps, wrist flexors, wrist extensors, and intrinsics for both the right and left, although there is some decrease on the right which appears to be secondary to pain. The lower extremities have 5/5 muscle strengths for all motor groups. There is no calf pain. There is a 2+ pulse for the radial, dorsalis pedis, and posterior tibial pulses. The deep tendon reflexes are 2+ for biceps, triceps, brachioradialis, knee flexion, and knee extension.

IMPRESSION: Herniated cervical disk.

PLAN: Myelogram today and anterior cervical fusion tomorrow.


I just gave this a quick glance and put the changes in red. I don't have a sound file to listen to so some of this is my MT "hunch" on what you're trying to say. As far as the word disc versus disk... most of my accounts prefer disc (with a C for eyes) and disk (with a K for cervical, thoracic, lumbar region). I grouped your HEENT, eyes, pharynx all together because this would all be included in HEENT (head, ears, eyes, nose, throat). The allergies section is usually put in all caps and/or bolded depending on your account's requirements. They usually want allergies and code status to stand out.

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#14044 - 10/23/11 10:14 PM Re: feed back please any info on proofread for errors [Re: MTTerri]
LuvScrapbooking Offline
Gabber

Registered: 10/06/11
Posts: 11
Loc: VA
Which quiz is this from?

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