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#15511 - 01/24/12 06:06 AM Quiz 36 report 21.
lmcmullen30 Offline
Gabber

Registered: 11/04/11
Posts: 14
Loc: Soldotna, Alaska
I did what you suggested with writing in the search. thank you for letting me know but still have some question with some of the reports.

Terry McGill
PMH
Illnesses and Surgeries: Appendectomy age 12. Bilateral __________ decompression_______

EXTREMITIES: Left Upper Extremity: There is a 1 cm squared dusty, dry scar over the proximal owner. No discharge from the wound is seen. There is minimal tenderness. There is erythema, cellulites, streaking. There is full range of motion of the elbow with flexion and supination??? and pronation???? without pain. Gripping upper extremities is 5/5 bilaterally. Pulses are equal bilaterally. Reflexes are equal bilaterally.

Marla Adams

ANESTHESIA: The patient was premedicated with atropine 0.6 mg IM. The patient was also given 8 mg morphine sulfate IV and 25 mg valum IV during the procedure. Lidocaine spray 1% approximately 10 mL.

LOWER AIRWAY EXAMINATION: Tracheal mucosal was within normal limits. There was minimum amount of secretion. The main carina was sharp and within normal limits. Both mainstem bronchi were examined to subsegmental level. No endobronchial abnormality was noted.

Patrick Monterey
SKIN: There are hyperpigmented area in both inguinal areas due to an old rash.

HEENT: Anisocoria, the right pupil measuring 4mm the left 2mm. The extraocular muscles are intact. There are no capillary annurysm, hemorrhage, exudates at funduscopic examination. TMC intact. The nasal and oramicles are pink and moist. The trachea is midline. No thyromegaly is palpated.

CRANIAL NERVES: II-XII are grossly intact. Pinprick position and vibration testing are normal. No Brudzinski or Kernig signs are present. No ________ intention, tremor or rapidal tration movement are present.

Jason Lopez
PE 24.Blood pressure: 105/70.
WEIGHT: 20 kgm.

Sherry West

Procedure
All vital signs being stable the patient was induced with general anesthesia via the nasotracheal route.

This was ligated into place utilizing a 24 gauge stamosteel wire.
Utilizing a #15 Bard-Parker blade reincised to the mucosa to the area approximately to the third molar.

At which time we strapply dissected down to the periosteum. Metzenbaum scissors were utilized to bluntly dissect through the maseter muscle in this region

establish a medial lymloade through which we

placed a vertical ostotomy through the lateral cortex on the left side justicle to the second molar. Once this had been accomplished we utilized the smaller reciprocating saw to connect the two osteotomies along the superior ridge. At this time, utilizing straight chisels we introduced three ribbon chisels at the area of the vertical osteotomy and the splint was accomplished with a little


Marianne
Cervical intraepithelial neoplasia, grade 3, on

Primary procedure

1. ________ BIOPSY.

finding and procedure

Examination under anesthesia demonstrated a small cervix and uterus without any _____ and masses.

Endocervical curettage was performed and _________ curettage was then performed.

Are there suppose to be there own headings with these.

Anesthesia: General endotracheal. Estimated blood loss: 10mL. Intravenous fluid: 1600 mL. Line: IV and arterial line. Urinary output during procedure 700 mL. Drain noncount correct. The specimen was sent to pathology ______ one _______biopsy. 2. Endocervical curettage. 3. Endometrial curettage. Urine was sent for cytology.


Thank you smile

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#15522 - 01/25/12 05:24 AM Re: Quiz 36 report 21. [Re: lmcmullen30]
judymae Offline
Supreme Gabber

Registered: 07/13/11
Posts: 471
Loc: Medon, Tennessee

Terry McGill
PMH
Illnesses and Surgeries: Appendectomy age 12. Bilateral ulnar nerve decompression. Traumatic

EXTREMITIES: Left Upper Extremity: There is a 1 cm squared dusty, dry scar over the proximal owner ulna. No discharge from the wound is seen. There is minimal tenderness. There is no erythema, cellulites, streaking. There is full range of motion of the elbow with flexion and supination (??? correct) and pronation (???? correct) without pain. Gripping Grip in the upper extremities is 5/5 bilaterally. Pulses are equal bilaterally. Reflexes are equal bilaterally.

Marla Adams

ANESTHESIA: The patient was premedicated with atropine 0.6 mg IM. The patient was also given 8 mg morphine sulfate IV and 25 mg Valum IV during the procedure. Lidocaine spray 1% approximately 10 mL.

LOWER AIRWAY EXAMINATION: Tracheal mucosal was within normal limits. There was minimum amount of secretion. The main carina was sharp and within normal limits. Both mainstem bronchi were examined to subsegmental level. No endobronchial abnormality was noted.

Patrick Monterey
SKIN: There are hyperpigmented areas in both inguinal areas due to an old rash.

HEENT: Anisocoria, the right pupil measuring 4 mm, the left 2 mm. The extraocular muscles are intact. There are no capillary annurysm, hemorrhage or exudates at funduscopic examination. TMC TMs intact. The nasal and oramicles oral mucosa are pink and moist. The trachea is midline. No thyromegaly is palpated.

This s/b under NEUROLOGIC: Cranial nerves CRANIAL NERVES: II-XII are grossly intact. Pinprick, position and vibration testing are normal. No Brudzinski or Kernig signs are present. No nystagmus intention, tremor or rapidal tration alternating movements are present.

Jason Lopez
PE Respirations: 24.Blood pressure: 105/70. Weight: 20 kg.
WEIGHT: 20 kgm.

Sherry West

Procedure
All vital signs being stable, the patient was induced with general anesthesia via the nasotracheal route.

This was ligated into place utilizing a 24-gauge stamosteel stainless steel wire.
Utilizing a #15 Bard-Parker blade, we reincised through to the mucosa to the area approximately to the third molar, at which time we strapply dissected down to through the periosteum. Metzenbaum scissors were utilized to bluntly dissect through the masseter muscle in this region

establish a medial lymloade envelope, through which we

placed a vertical ostotomy through the lateral cortex on the left side justicle just distal to the second molar. Once this had been accomplished, we utilized the smaller reciprocating saw to connect the two osteotomies along the superior ridge. At this time, utilizing straight chisels, we introduced three ribbon chisels at the area of the vertical osteotomy, and the splint was accomplished with a little


Marianne
Cervical intraepithelial neoplasia, grade 3, on

Primary procedure

1. CONE BIOPSY.

finding and procedure All Caps
Examination under anesthesia demonstrated a small cervix and uterus without any adnexal and masses.

Endocervical curettage was performed. and Endometrial curettage was then performed.

Are there suppose to be there own headings with these. No, continue on in the paragraph.

Anesthesia: General endotracheal. Estimated blood loss: 10mL. Intravenous fluids: 1600 mL. Lines: IV and arterial line. Urinary output during procedure 700 mL. Drains: None. noncount Count: Correct.

Start new paragraph with this
The specimen was sent to Pathology: (1) one Cone biopsy. 2. Endocervical curettage. 3. Endometrial curettage. Urine was sent for cytology.


Hope this helps,
_________________________
Judy

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#16538 - 04/06/12 08:19 PM Re: Quiz 36 report 21. [Re: judymae]
2manyhours Offline
Newbie Gabber

Registered: 03/24/12
Posts: 9
Loc: Michigan
Could someone help me to figure out what the doctor is say here?

REVIEW OF SYSTEMS: No allergies, fatigue, headache, fever, chills, diplopia, loss of vision tinnitus, ? , epistaxis, hoarseness or dysphagia. The patient has dyspnea on exertion and chest pain on exertion without history of palpitation. Wheezing, ? or nocturnal dyspnea.

PE HEENT: No ?? of the heart sound is heard.



Edited by 2manyhours (04/06/12 09:42 PM)

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#16545 - 04/09/12 04:45 PM Re: Quiz 36 report 21. [Re: 2manyhours]
leanne Offline
Veteran Gabber

Registered: 09/10/11
Posts: 160
Loc: Nebraska
? #1 otorrhea
palpitation should be plural, palpitations
? #2 . . . palpitations, wheezing, orthopnea or nocturnal . . .
? #3 This is a separate heading for HEART: S1 and S2 and heard in all valve areas . . . No splitting of the heart sounds is heard.

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#16563 - 04/10/12 04:15 AM Re: Quiz 36 report 21. [Re: leanne]
leanne Offline
Veteran Gabber

Registered: 09/10/11
Posts: 160
Loc: Nebraska
Just noticed I had a typo in my reply!!!
For ? #3 HEART: S1 and S2 are heard . . . (not "and" heard).
Sorry!!!!

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