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#14565 - 11/19/11 09:34 AM ATHP Quiz 18 Mimi Green (Proof Read)
sln Offline
Seasoned Gabber

Registered: 10/30/11
Posts: 94
Loc: ar
Good morning all.

Can anyone please proof read this report?

Name: Mimi Green DISCHARGE SUMMARY
#030522
Dr. Anne Jones

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS
Intermittent claudication.

HISTORY OF PRESENT ILLNESS
The patient was admitted with intermittent pain with walking and claudication after one block of walking.

PERTINENT PAST HISTORY
Patient was admitted after abnormal physical examination by LMD. Blood pressure: 106/60. Cardiac examination: Regular sinus rhythm S1 and S2 are heard in all areas. No murmurs, gallops or rubs are heard. Femoral, popliteal, posterior tibial and dorsalis pedis pulses are 1+ on the left and 0 on the right. There is a 10 cm pulsatile mass in the paraumbilical region of the abdomen.

LABORATORY FINDINGS
Aortic sonography shows a large aortic aneurysm that extends from at least the level of the diaphragm to the renal arteries. Thoracoabdominal CT demonstrated an aneurysm extending from the aortic valve to the level of the renal arteries. EKG normal. Doppler 2D echocardiogram normal.

HOSPITAL COURSE
On the third hospital day, a Type 1 aortic aneurysm repair with graft replacement was performed. The postoperative course was uneventful.

DISPOSITION
Discharged to home with visiting nurse daily, to monitor peripheral pulses.

FOLLOW-UP
Return to Cardiovascular Surgery Clinic in seven days.

CONDITION ON DISCHARGE
Good.

DISCHARGE DIAGNOSIS
1. Thoracic and aortic abdominal aneurysm sparing the renal arteries. Status post graft replacement.
2. Diffuse atherosclerotic disease without clinical evidence of coronary artery disease.

CONTINUED

Name: Mimi Green DISCHARGE SUMMARY
#030522
Dr. Anne Jones Page 2

PROGNOSIS
Good.

DISCHARGE MEDICATIONS
Inderal 20 mg 1 p.o. q.i.d.

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#14567 - 11/19/11 02:07 PM Re: ATHP Quiz 18 Mimi Green (Proof Read) [Re: sln]
ursula38 Offline
Seasoned Gabber

Registered: 07/12/11
Posts: 42
Loc: ID
Sorry, wanted to help you but my Quiz 18 is different from yours

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#14570 - 11/19/11 03:56 PM Re: ATHP Quiz 18 Mimi Green (Proof Read) [Re: ursula38]
sln Offline
Seasoned Gabber

Registered: 10/30/11
Posts: 94
Loc: ar
Thank you for taking the time to look over it.


Are you taking the At-Home professionals?


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#14574 - 11/19/11 05:01 PM Re: ATHP Quiz 18 Mimi Green (Proof Read) [Re: sln]
caw Offline
Supreme Gabber

Registered: 06/10/11
Posts: 383
Loc: Indiana
PERTINENT PAST HISTORY
(last sentence) ...periumbilical region..

HOSPITAL COURSE
, a type 1 aortic..(lower case "t")

No comma after daily.

..cardiovascular surgery clinic..(lower case)

DISCHARGE DIAGNOSIS
1. Thoracic and abdominal aortic aneurysms, sparing...

You did a good job. Those couple of mistakes wouldn't have hurt you much on your grade.

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#14575 - 11/19/11 05:20 PM Re: ATHP Quiz 18 Mimi Green (Proof Read) [Re: caw]
sln Offline
Seasoned Gabber

Registered: 10/30/11
Posts: 94
Loc: ar
Thank you caw, your help is very appreciated. wink

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#14791 - 12/06/11 09:30 AM Re: ATHP Quiz 18 Mimi Green (Proof Read) [Re: sln]
J-Bird Offline
Newbie Gabber

Registered: 11/15/11
Posts: 4
Loc: Minnesota
My question is on the Mimi Greene Discharge Summary is if a date is not dictated, do we have to put one down on our transcription?

Thanks to whomever can help.

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#14794 - 12/06/11 10:52 AM Re: ATHP Quiz 18 Mimi Green (Proof Read) [Re: J-Bird]
Lakelife Offline
Supreme Gabber

Registered: 08/10/11
Posts: 447
Loc: Minnesota
The only dates on the Mimi Greene DISCHARGE SUMMARY is at the end of the report. Date dictated and date transcribed. None at the beginning.
_________________________
A moving target is hard to hit. I am never going to get old. If I keep moving, old age can not catch up with me.

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#14936 - 12/14/11 08:11 AM Re: ATHP Quiz 18 Mimi Green (Proof Read) [Re: Lakelife]
ValleyGirl0205 Offline
Seasoned Gabber

Registered: 10/07/11
Posts: 57
Loc: PA
Am I missing something here? On the Mimi Greene transcript (Quiz 32), there were no dates transcribed at the end of the report. It goes right into the next one with Sansuk Sudsai dictating. If none are transcribed, do we not put in those headings or do we flag those areas?

In the foot notes, it states that any dates dictated are indicated after the title.

Thanks for the clarification...

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