Medical Notes

252 Book reviews
valuable and beautifully illustrated work, very adequately

covering their subject. The head and neck structures are
encompassed in depth, but the central nervous system is
covered in much less detail and from the perspective of a
head and neck radiologist rather than a neuroradiologist.
Thus the basal cisterns, cranial nerves and basal arteries are
illustrated and described but not the intrinsic structure of
the central nervous system.
The book is highly recommended to radiologists in

training, radiologists and all other specialists with an interest
in the head and neck as well as to students of anatomy.
BRIAN KENDALL
Concepts of Human Anatomy and Physiology, 4th

edn. By KENT M. VAN DE GRAAF and STUART IRA
Fox. (Pp. xix+ 1002; fully illustrated in colour
and black & white; includes CD Rom; �21.95
hardback; ISBN 0 697 16076 9); Dubuque and
Guildford: William C. Brown. 1995.
As a retired surgeon teaching preclinical anatomy in Britain

I am depressed that it has changed little since I taught it 40
years ago. For as long as I can remember there has been talk
of 'integrated teaching'. The trouble is that there are very
few integrated teachers-and teaching is undervalued. It
does not bring in research grants. As a result our students
learn lots of useless facts but have little understanding.
This American book shows how we should do it. With

brightly coloured illustrations it carries us from atoms, ions
and molecules through to systematic anatomy, biochemistry
and physiology. New words are explained, and even their
pronunciation is given. There is a glossary, a list of prefixes
and a list of suffixes. Each chapter begins with a detailed list
of contents and outline of objectives. At the end is a
summaryandanopportunity to testknowledgewithMCQs
and short answer questions. It is possible to dip into the
book without starting at the beginning. There are associated
videotapes and a CD Rom.
No, it does not have lists of relations of structures and

detailed root values for every muscle. However, I believe
that ifourpreclinical students spentayearbeingexcited by,
and gaining an understanding of, the structure and function
ofthehumanbody in themanner setoutby thisbook, they
would not look like dull zombies until they embark on their
clinical studies. Are there any people out there in British
anatomy and physiology departments interested in producing
inspired doctors?
R. M. KIRK
Sex Determination, Differentiation and Intersexuality
inPlacentalMammals.ByR. H. F.HUNTER. (Pp.
xxi+310;illustrated;�50/$79.95hardback;ISBN
0 521 46218 5.) Cambridge: Cambridge University
Press. 1995.
This elegant and informative book is devoted to sex

differences and the process of differentiation in the gonads,
the reproductive tract and the genitalia. It tells its story
through 10 chapters, the first of which is devoted to
historical landmarks. Historical reviews seem de rigueur in
any book on sex and reproduction I doubt they occur so
regularly in major texts on the skin, kidneys or salivary
glands-but this one is relatively succinct. It does, however,
contain one of the few genuine oddities of the book, a two-
page table devoted to famous reproductive biologists

associated with Edinburgh University. The word
'associated' is apt, for the list certainly includes some whose
prominence was achieved elsewhere and some who (I am
told) were not always favourably disposed to their alma
mater; a future edition woulIG benefit from a little less 'Auld
Reekie'.
Chapter 2, on Mechanisms of Sex Determination, is

concerned exclusively with genes and their actions. The
inactiveX(Lyonhypothesis), sex-determininggenesandH-
Y antigen receive full consideration, with an interesting
aside on the links between ideas on sex reversal and the
testis-determining geneon theYchromosome. Accelerated
growth in male embryos as a genetic (pregonadal) phenomenon
is also explored; one wonders what the situation is for
mammals in which the female is bigger the golden hamster
is a ready example.
Chapter 3 deals with differentiation of the gonads and

reviews the origin, migration and multiplication of primordial
germ cells before dealing with the formation and
differentiation of the testis and ovary. These are all themes
where the gaps in our knowledge are wide and Hunter
handles these well, though there is little on gonadal
histogenesis and its stages. Descent of the gonad also
receives a rather short consideration which, given the
relativefrequencyofmaldescentofthe testisand thelackof
consensus over mechanisms (androgens and 'descendin' are
commented on, GAGs and CGRP are not), is perhaps a
pity.
Chapter4 isdevoted to differentiationofthereproductive
tract and genitalia. After an initial description of the events
in both sexes, most of the chapter deals with control
processes. There is unequal weight here, with the greatest
emphasis on antimullerian hormone (AMH) and the
degeneration of the paramesonephric duct in males. This is
understandable; the discovery ofAMHis a classic scientific
set-piece, and due homage is paid to Nathalie Josso and
others. Nevertheless, there are omissions regarding the role
of the testis in maintaining the wolffian duct; the existence
ofaseparatefetal/neonatalpopulationofLeydig cells isnot
discussed, nor is there any consideration of whether these
are controlled by a functional fetal hypothalamopituitary
system.
Chapters 5-7 can be considered together since they deal

with spontaneous anomalous development in farm animals,
laboratory rodents and humans respectively. There is an
initial temptation to wonder why three chapters were
necessary, since the mechanisms are much the same for all
eutherian mammals, but the author is very much on home
territory and each chapter permits different kinds of
examples to be used. Freemartins and intersexes are
naturally to the fore in the chapter on domestic animals,
while that on laboratory rodents deals almost wholly with
mutants (sex reversals, hypogonadal and testicular
feminising syndromes, etc.) but with a brief nod to
transgenics. The chapter on human anomalies again
concentrates on genetic disorders and there is thus no
reference to female offspring virilised by synthetic steroids
aimed at preventing miscarriage ('progestin-induced hermaphroditism')
so classically reported on by Money,
Ehrhardt and others. 5a-reductase deficiency is mentioned
as a rare recessive syndrome but with no indication of the
appearance ofsuch individuals nor that, in some parts ofthe
world, they were held to change sex miraculously from
female to male at puberty.
Chapter 8 differs from the last three in that it discusses sex

differentiation in chimaeras, and thus mixes the spontaneous
with the experimentally derived. Chapter 9 deals with the
The human body is the entire physical structure of a human organism. The human
body consists of a head, neck, torso, two arms and two legs. The average height of
an adult human is about 1.6 m (5 to 6 feet) tall. This size is largely determined
by genes. Body type and body composition are influenced by postnatal factors such
as diet and exercise.
The human body is often called a "body". The body of a dead person is called a
"corpse" or "cadaver".
The human body consists of systems, organs, tissues and cells. Human anatomy
studies structures and systems of the human body. The study of the workings of the
human body is called physiology. Ecology focuses on the distribution and abundance
of the bodies and how the distribution and abundance are affected by interactions
between bodies and its environment.
Combination of individual atoms, molecules, polypeptides, cells in human body, is

a source of emergence.
The study of anatomy proceeds along two different lines at the same time, regional
anatomy and systemic anatomy. Regional
anatomy looks at the body according to structure and location, e.g. the eye and
the head. When students dissect cadavers,
this is the approach that is taken. The systemic approach divides the body
according to function, e.g. the digestive system.
The regional approach is of great importance, especially for the surgeon. At the
same time a systemic knowledge of anatomy allows one to understand how the
different parts of the body interrelate.
Many branches of anatomy, e.g. functional anatomy, overlap with physiology.
Branches of anatomy include comparative anatomy,
functional anatomy, developmental anatomy, pathological anatomy, gross anatomy,
microanatomy, histology, and c
CARDIOPULMONARY DICTATION #1
INITIAL OFFICE EVALUATION (2:30)
CHIEF COMPLAINT
Productive cough, chest pain, fever.
HISTORY OF PRESENT ILLNESS1
This 56-year-old white female, nonsmoker, has had a gradually worsening cough for
about 4 weeks. This
began as an upper respiratory infection (URI)2 and moved into her chest. Her cough
produces thick3
yellow sputum especially in the morning. Coughing keeps her awake at night. She
has coughed to the
point of gagging and vomiting on 2 occasions. She has been sweating heavily during
the night for the past
4 or 5 days. Her appetite is down, and she gets winded climbing stairs. She denies
hemoptysis or
wheezing. She denies sore throat. Her chest is sore from coughing, but she denies
pleuritic chest pain.
PAST MEDICAL HISTORY4

She denies any history of asthma. She has never smoked. She has no known
allergies. She had pneumonia
in her teens and gets bronchitis �every winter.� She is on Dyazide for
hypertension and Timoptic for
glaucoma. She has been taking Nyquil, Contac, Vicks Formula, Robitussin-DM, and
Alka-Seltzer Plus in
various combinations without relief. Past medical and5 surgical history is
essentially negative.
REVIEW OF SYSTEMS
Negative.
PHYSICAL EXAMINATION
Temperature 99.5, pulse 97, respirations 22, blood pressure 160/100. This is a
normally developed and
nourished woman appearing the stated age of 56 years. She is alert, cooperative,
and in no distress. She is
eupneic at rest. Her skin is flushed, warm to the touch, and moist. She coughs
frequently, and this is a
harsh, crackling, bronchial-type of cough. Pharyngeal mucosa is normal in color
and normally hydrated,
without lesions. No neck masses are palpable. Respiratory excursions are full and
equal without splinting.
On auscultation there are inspiratory rhonchi over the bases and the right upper
lobe. No rales or rubs are
heard. The percussion note is resonant throughout the chest, and diaphragmatic
excursions are full and
equal.
DIAGNOSIS
Acute bronchitis, classification 466.0.6
PRESCRIPTIONS7
Amoxil 500 mg t.i.d. for8 10 days.
Organidin tabs 2 q.i.d. with a full glass of water or juice each time.
Discontinue9 all other medicines. Force fluids. Return in 7 days, sooner p.r.n.
2172 characters
�2005, Health Professions Institute80http://www.hpisum.com

1 Expand all abbreviations in headings.
2 Expand an abbreviation on first use in the body of a report and place the
abbreviation itself within parentheses.
Change the article from a to an for proper usage.
3 Alternative: A comma between �thick� and �yellow� to indicate the sputum is both
thick and yellow.
4 Expand all abbreviations in headings..
5 Alternative: Omit medical and since this is the Past Medical History. Do not
paragraph before �past medical and
surgical history,� as instructed by the dictator.
6 This is an ICD-9-CM code that is assigned for the purposes of billing for
reimbursement.
7 Edit �Rx� to Prescriptions.
8 When the word times is dictated in dosage instructions, it should be translated
as for rather than times or x.
9 The abbreviation DC or D/C (discontinue or discharge) is on the list of
dangerous abbreviations and should be
translated appropriately based on context.

OFFICE NOTE (2:00)
A 50-year-old white male, well known to me, who continues to complain of upper
respiratory tract
infections including cough and hoarseness. He denies ear or1 eye problems. Does
admit to nose being
slightly stuffy at this time. He presents with an obvious cough unproductive at
the present time that has
been persistent for the last 10 days and apparently not well controlled with cough
formula. He denies stiff
neck or chest congestion or abdominal discomfort. He reports positive fever and
chills. No nausea,
vomiting, or diarrhea. He states that his upper respiratory tract infection
treated 1 week ago actually
improved until 2 days ago, at which time he apparently got symptoms again
suggestive of a new
infectious process.
OBJECTIVE
Alert, oriented white male in no acute distress at the time of examination. Vital
Signs2: Temperature 98.7,
pulse 80, respirations 14, blood pressure 152/106 right, 154/106 left. HEENT:
Normocephalic,
atraumatic. Tympanic membranes clear bilaterally with good light reflex. Eyes:
Pupils equal, reactive to
light and accommodation. Extraocular movements intact (EOMI).3 Disks sharp. Nares:
Erythematous,
boggy mucous membranes with clear discharge noted. Pharynx: Beefy red pharynx. No
exudate. Neck:
Supple. Trachea midline. Chest: Clear to auscultation bilaterally without wheeze
or rhonchi. Abdomen:
Soft, nondistended. Negative for hepatosplenomegaly. Extremities: Without edema.
ASSESSMENT
A 50-year-old white male with continued upper respiratory tract infection, and now
with mild diastolic
hypertension, which I suspect is secondary to coughing.
PLAN
1.
Treat bronchitis with erythromycin 250 mg p.o. q.i.d. for4 7 days.
2.
Will treat cough with Robitussin A-C 1-2 teaspoons p.o. q.4 hours5 p.r.n. cough.
Although patient has
noted allergy to codeine in past, a recheck on patient at home states no adverse
reactions to this cough
formula containing codeine.
3.
Symptomatic treatment for sore throat: Listerine, Cepacol mouthwash, throat
lozenges, cool fluids,
etc.
4.
Follow up in 1 week if not improved.
2076 characters
1 Insert or for proper usage.

2 Use initial caps on each word of a subheading.
3 Expand an abbreviation on first use and place the abbreviation within
parentheses.
as for rather than times or x.
5 The dictator says �q.4 hours� which is a common mixing of Latin and English
forms. Alternative: q.4 h. or every 4
hours.

OFFICE NOTE (3:30)
Patient presents this date a 2- to 3-week history of swelling of the left leg that
started with soreness in the
left ankle, and she does notice some swelling up from the ankle from time to time.
She has also noticed
some nighttime increased urinary frequency up to 2 times nightly which she has not
had before. She has
had1 no significant urgency, she noted no hematuria, and so on. She had no
significant change in bowel
habits. She did have a routine flexible sigmoidoscopic examination 3 years ago in
this facility, which was
negative. Patient also has chief complaint of increased swelling of the lower
abdominal girth, which2 is
sort of vague, that has been somewhat more apparent in the last few weeks. She
gives a history of having
had the flu around the first of the year, was in bed at her home for approximately
1 week, and is feeling
much better from that standpoint at the present time.
EXAMINATION THIS DATE

The blood pressure as recorded. The apical rate was 70. Patient has an3 obvious
gallop at this time that
has not been noted previously. No significant murmur is noted. The lungs were
relatively clear to
auscultation and percussion both anteriorly and posteriorly. Patient does have
some tenderness over the
upper outer quadrant of each breast, possibly of fibrocystic nature. No
significant adenopathy noted in
either4 axilla. I noticed no adenopathy in either supraclavicular5 or
infraclavicular areas, right or left. The
breasts otherwise felt normal. The abdomen was soft, nontender. Patient has a
well-healed lower midline
incision from abdominal hysterectomy. She has no focal tenderness in the abdomen
in either quadrant. No
masses noted in any quadrant of the abdomen. Auscultation of the abdomen was
significant in that she
does have significant bruits noted in both femoral areas, with the lesser bruit
noticed in the left. Pelvic
examination was compromised because of a tight vaginal introitus, unable to use a
speculum; however,
bimanual examination was entirely within normal limits. The adnexal area is
entirely normal. No fullness
noted. Rectal examination likewise was essentially normal. Hemoccult negative on
the examining glove.
Femoral pulses were diminished in both right and the left, somewhat more on the
left side. Patient has
diminution of all peripheral pulses in lower extremities with her left foot being
appreciably colder than
her right foot temperaturewise.
IMPRESSION
Significant peripheral vascular insufficiency, more prominent on the left,
possibly secondary to
generalized atherosclerosis.
PLAN
EKG and repeat chest x-ray. Patient was started with Trental to be taken b.i.d.
along with ASA daily for
her circulation. To return for reevaluation and results of blood tests in 3 weeks.
Must consider a future
mammography on this patient.
2803 characters

Expand contractions except in direct quotations.
Use which instead of that to begin a nonessential clause.
Edit dictated a to the appropriate article an before a vowel sound.
Edit dictated each to either for correctness.
The dictator said �supra- or infraclavicular.� Do not use a suspensive hyphen in
constructions that are not
normally hyphenated.

PREOPERATIVE NOTE (0:30)
The patient is a 39-year-old female who underwent clipping of a cerebral aneurysm.

Since then she has
had ventilator dependence. She therefore needs a tracheostomy to assist with
weaning off the ventilator
and a percutaneous endoscopic gastrostomy for prolonged nutrition support.
304 characters

HISTORY AND PHYSICAL EXAMINATION (1:30)
CHIEF COMPLAINT
Shortness of breath.
HISTORY OF PRESENT ILLNESS

This 77-year-old Caucasian male has severe chronic obstructive pulmonary disease
(COPD)1. Apparently
he went into rapid atrial fibrillation, developed extreme shortness of breath, and
was taken to the
emergency room. There2 he was found to be in atrial fibrillation at 136 beats per
minute, and he was
wheezing and apparently in congestive heart failure and respiratory distress.
GENERAL:3 On physical exam he is flushed, elderly.
VITAL SIGNS: Blood pressure 152/70, pulse 122, respirations 20.
HEENT: Clear.
CHEST: Increased AP diameter.
LUNGS: Wheezes and rhonchi bilaterally.
HEART: Atrial fibrillation with rapid response.
LABORATORY WORK
Serial EKGs showed no acute infarction. Digoxin level therapeutic at 0.64.
Theophylline level therapeutic
at 17. Glucose slightly elevated at 159, sodium 130, potassium 3.8. White count
elevated at 12,800 with
79% segs. Chest x-ray showed chronic obstructive pulmonary disease. No acute chest
pathology. EKG:
Atrial fibrillation. No signs of acute myocardial infarction (MI). Blood gases:5
pO2 83, pCO2 40, pH 7.45
on room air after treatment.
INITIAL IMPRESSION
Acute decompensation of chronic obstructive pulmonary disease (COPD)6 and
congestive heart failure
secondary to rapid atrial fibrillation.
1357 characters

Expand an abbreviation on first use and place the abbreviation within
parentheses.
A comma is optional after the introductory There (an adverb in this sentence, not
an expletive).
Headings are added for consistency in format.
The dictator says �point 6.� Add a zero before the decimal for values under 1.
Alternative: PO2, PO2, PCO2, PCO2.
Expand an abbreviation in the diagnosis or impression and place the abbreviation
within parentheses.

EMERGENCY DEPARTMENT REPORT (2:00)

Patient was a passenger in a car that was hit at high speeds. Patient was ejected
from the car. On the
paramedics� arrival, there were some life signs. She was intubated and coded.
During her transport to the
ER, she had apparently 2 episodes of ventricular fibrillation that were
countershocked. An IV was not
established.
PHYSICAL EXAMINATION1
Physical exam showed a 40-ish-year-old2 female without spontaneous respirations,
without pulse, without
blood pressure. Cardiac monitor showed an agonal ventricular rhythm. Pupils were
fixed and dilated.
There was some blood from the right naris. No blood was noted from the tympanic
membranes (TMs)3.
There was abrasion over the right parietal scalp. Pharynx was not viewed. Neck
showed swelling in the
right anterior cervical area. The chest had crepitus throughout all lung fields.
Pelvis seemed intact. Lower
extremities showed severe lacerations and probable fractures bilaterally.
EMERGENCY ROOM COURSE

Patient was placed on cardiac monitor. One ampule4 of bicarbonate5 was given when
the IV line was
established. Epinephrine 1 ampule6 was also ordered but apparently not given. She
went into a coarse
ventricular fibrillation and was countershocked by myself with 300 watts.7 After
the countershock, the
patient had an8 agonal bradyrhythmia9 at a rate of approximately 15 beats per
minute. At this point, our
assessment showed probable critical brain injury with neck, chest, and extremity
trauma, without vital
signs. The Code Blue was called. Patient was pronounced dead by myself. Coroner
was called.
1610 characters
1 Headings are added for consistency in format.

2 An awkward adjective 40-ish is dictated. It is hyphenated by analogy with the
suffix -odd, as in 60-odd.
parentheses.
4 Expand unacceptable brief forms.
Expand unacceptable brief forms.

7 Although �watts� is dictated, watt-seconds or joules is meant.
8 Edit a to the appropriate article an before a vowel sound.
9 Edit �bradyrhythm� (not a word) to bradyrhythmia.

DISCHARGE SUMMARY (3:00)
DISCHARGE DIAGNOSES
1. Right lower lobe pneumonia secondary to pseudomonas.

2. Congestive heart failure.
3. Atrial fibrillation with rapid ventricular response, resolved.
4. Alzheimer�s1 disease.
PROCEDURES
Central venous catheter placement.
CONSULTATIONS
None.
SUMMARY
The patient is a 73-year-old white male with Alzheimer�s disease. The patient was
markedly dyspneic
with a respiratory rate of 32, temperature 99.5 rectally, a blood pressure of
100/70, pulse irregular at 120
130. The patient showed dry oral mucosa with flat neck veins. The chest showed
some rhonchi and
bronchial breath sounds in the right base. The heart was irregularly irregular. No
S32 noted. Extremities
were cold with palpable pulses, and skin turgor was decreased.3
Laboratory data was significant for a hemoglobin of 10.2, hematocrit of 31.2, with
a white blood cell
count of 22,500. Platelet count was 806,000. MCV normal at 87. The original
hemoglobin was 22.1 and
hematocrit4 66.9 secondary to the patient�s severe dehydration. Sodium was 130,
potassium 4.1, a glucose
of 157, a BUN of 18, creatinine 0.8.5 Arterial blood gases on 6 L nasal cannula
was a pO2 of 42, pCO2 of
356 and pH of 7.49. Chest x-ray showed a right lower lobe infiltrative process.
EKG was atrial fibrillation
with a rapid ventricular response at 120-130. No acute ST-T wave changes. The
patient was admitted to
the progressive care unit, where he was started on 100% nonrebreather mask, Ancef
1 g IV q.6 hours,7
gentamicin 100 mg IV load and 60 mg IV q.12 hours8. Blood cultures x2 were
obtained, which were
negative. Sputum for culture and sensitivity grew out pseudomonas moderately
sensitive to both the
Ancef and the gentamicin. The patient was started on IV fluid hydration, D5 in
half-normal saline,9 with
20 KCl/L at 75 mL/h10 due to the patient�s history of coronary artery disease. The
patient developed some
fluid overload and lost IV access. He required a central venous catheter to be
placed in the right internal
jugular vein, which was done without difficulty. The patient was treated with IV
Lasix, Lanoxin 0.125 mg
p.o. q. day11 with resolution of the patient�s fluid overload and congestive heart
failure. The patient also
improved on the antibiotic treatments with clearing of the right lower lobe
infiltrate over the next several
days. Gentamicin levels returned therapeutic and it12 was discontinued after 5
days of treatment. The
patient was continued on Ancef and continued to improve. The patient was noted to
have a drop in his
hemoglobin to 7.7 and was transfused 2 units of packed red blood cells. After
transfusion of the 2 units,
his hemoglobin stabilized at 11.5.
At the time of discharge, the patient is stable off13 oxygen and has been
restarted on his feedings of
Ensure Plus 40 mL/h14 per enteral feeding tube. The patient will be discharged on
the following
15 16
medications: Lanoxin 0.125 mg p.o. q. day,Keflex 500 mg p.o. q.6 hours for 5 days,
Lasix
20 mg p.o. q. day, K-Dur 20 mEq p.o. q. day, Kaopectate 30 mL17 p.r.n. diarrhea,
Tylenol 650 mg p.o. or
suppository q.4 hours18 p.r.n. pain or discomfort. He is to receive Ensure Plus
full strength at 40 mL/h19
per enteral feeding tube. The head of his bed should be elevated at all times to
30�, and his activity will be
out of bed to chair as tolerated.
3303 characters
1 Alternative: Alzheimer. The use of the possessive form of eponyms is acceptable

when it is dictated or when it is
preferred by the employer or client.
2 Alternative: S3.
3 A new paragraph is needed for presentation of the laboratory data.
4 It is appropriate to add hematocrit as it is clear from the context that the
value 66.9 refers to the hematocrit.
Alternative: Leave a blank and flag the missing term.
5 The dictator says �point 8.� Add a zero before the decimal for values under 1.
6 Alternative: PO2, PCO2, or PO2, PCO2.
7 Alternative: q.6 h. or every 6 hours. Mixed Latin and English abbreviations such
as q.6 hours have become
commonplace.
8 Alternative: q.12 h. or every 12 hours.
9 To avoid errors or confusion, the dictated �D5/normal saline� (a mixture of
dextrose and saline) should be written
D5 in half-normal saline.
10 The dictated �cc� is on the dangerous abbreviations list and should be replaced
with mL (milliliter).
11 Alternative: daily or every day (but not q.d., as it is considered a dangerous
abbreviation).
12
The dictator says �and was discontinued.� Since it was the gentamicin that was
discontinued, not the gentamicin
levels, the pronoun it is supplied.
13 The dictator says �stable off of oxygen.� Delete the �of� following the
preposition �off.�
15 Alternative: daily or every day.

REASON FOR ADMISSION

This is an 85-year-old female whose history and physical is not on the chart. From
memory, the patient
has a history of arthritis, progressive in severity and disabling in intensity,
who about 2 weeks prior to
admission began experiencing pain in the right leg becoming severe.1 When seen in
the office on the day
of admission, the patient became dyspneic, cyanotic, with elevated blood pressure.
EKG showed changes
from previous cardiograms. Oxygen was administered, and the patient was sent to
the hospital by
ambulance and admitted to the progressive care unit for monitoring.
LABORATORY STUDIES2
EKGs on 3 occasions showed nonspecific changes without an evolution pattern of an
infarction. Arterial
blood gases done while the patient was on 4 L of oxygen per minute showed a pH of
7.45, pO23 of 40 and
a pO24 of 153. Echocardiogram was reported as �good left ventricular function,
small posterior pericardial
effusion, and slight calcification of the mitral anulus5 and sclerosis of the
aortic leaflets, but no stenosis.�
Urinalysis was unremarkable. Stools for blood were negative on 2 occasions.
Cardiac enzymes remained
within normal range. Chemistry profile showed an elevated cholesterol,
triglyceride, and a slightly
decreased sodium. Repeat BUN was reported as 26. CBCs on 3 occasions showed white
count up to
11,700 and a hemoglobin in the 11.5- to 12-g range. Chest x-ray was reported as
�no acute disease.�
COURSE IN HOSPITAL
The patient was admitted to the progressive care unit, where she was treated with
oxygen and monitored.
The dyspnea cleared. It was felt the patient�s condition had stabilized
sufficiently for her to be transferred
to a medical floor, where she was treated with analgesics and started on
prednisone.
DISPOSITION
The patient is returned to her home. She lives alone. Social Services6 has made
arrangements for the
patient to receive Meals on Wheels, and the patient will need some help with basic
care. The visiting
nurses have been asked to provide this. She is to continue prednisone 5 mg twice
daily as well as
allopurinol, trichlormethiazide, and Darvocet for pain. She is to be followed in
the office.
DISCHARGE DIAGNOSES7
Principal:8 Dyspnea, etiology undetermined.
Secondary diagnosis: Lumbar radiculitis. Generalized osteoarthritis.
CONSULTANTS
None.
PROCEDURES
None.
2341 characters

1 In the dictation, the antecedent for the pronoun who is patient but because of
the awkward construction of the
sentence, it may be recast for clarity. Alternative: From memory, the patient has
a history of arthritis, progressive in
severity and disabling in intensity. About 2 weeks prior to admission, she began
experiencing pain in the right leg,
becoming severe.
2 Expand brief forms in headings.
3 Dictation error: the dictator clearly says �PO2� both times, although research
would indicate the PCO2 is 40 and
PO2 is 153; however, on the job or in the classroom the transcriptionist would NOT
guess. The blood gases should
be flagged and clarification sought from the dictator or employer.
4 Dictation error: the dictator clearly says �pO2� both times, although one of
these values should be pCO2, probably
the first. Research would indicate the pCO2 is 40 and pO2 is 153; however, on the
job or in the classroom the
transcriptionist would NOT guess. The blood gases should be flagged and
clarification sought from the dictator or
employer.
5 Alternative: annulus.
6 Capitalize a department name that is referred to as an entity.
7 Alternative: In the absence of guidelines on how to format principal and
secondary diagnoses, other formats may
be chosen, including one in which the secondary diagnoses are numbered.
8 The word diagnosis may be added to match the format of the next line.

CHIEF COMPLAINT1
This is a 90-year-old house-confined amputee female who was admitted for
respiratory distress due to
acute bronchitis superimposed on severe chronic obstructive lung disease
aggravated by senile
emphysema.
HISTORY AND PHYSICAL EXAMINATION

The patient was in moderate respiratory distress on admission. It was deemed
appropriate to institute
intravenous steroids in addition to inhalant therapy, antibiotics, etc.
LABORATORY DATA2
She was found to be anemic, initial hematocrit 30 with an MCV of 105. X-ray was
consistent with
bronchitis but no definite infiltrate. T-wave changes on EKG were nonspecific.
Blood chemistries
basically normal except for a reduction of albumin and slight elevation of liver
function studies.
Theophylline levels were done for management purposes. Urinalysis unremarkable.
Folate level 17, B123
level 950. Blood cultures negative. Sputum culture, normal respiratory flora.
HOSPITAL COURSE4
The patient responded gradually but definitely to treatment for acute bronchitis
and improved. Steroids
were changed from intravenous to oral prednisone and tapered. Discharge
medications included
prednisone 20 mg a day for 1 week, then drop to 10 mg a day. Also an Atrovent
inhaler. Follow up in the
office. Home Health nursing visits were arranged.
CONDITION ON DISCHARGE
Poor.
PROGNOSIS
Guarded.
FINAL DIAGNOSIS
1. Acute bronchitis with respiratory distress.

2. Chronic obstructive lung disease.
3. Macrocytic anemia, cause undetermined.
4. Status post amputation of the left lower extremity above the knee.
1538 characters

2 A paragraph was inserted and the heading added for consistency in format.
3 Alternative: B12.
4 A heading was added for consistency in format.
The patient is a 70-year-old man who presented to the emergency room in full
cardiac arrest. CPR was
instituted along with intubation. Patient has a past history of hypertension. On
initial exam he was
comatose and intubated, with atrial fibrillation at a rate of 130-140 and a blood
pressure of 120/60. He
was ecchymotic over his left face. His neck was supple. He had no jugular venous
distention. Carotids
were 2+/2+. His chest was clear. He had decreased breath sounds at the left base.
Cardiac exam revealed
no murmur, gallop, or rub. Abdomen was soft, nontender, without organomegaly.
Peripheral pulses were
relatively intact. CAT scan of the head was performed which was negative. Patient
was seen by
Pulmonary1 after he was extubated because of a cuff rupture of the tube that2 was
uneventful. He was
noted to have bilateral infiltrates on chest x-ray, felt to have adult respiratory
distress syndrome (ARDS).3
The following day, with patient still on the ventilator, he spiked a temperature
to 106. Chest x-ray,
abdominal flat plate, amylase, lipase levels were all checked. A Swan-Ganz
catheter was placed in the left
subclavian vein. PA pressure was 39/20, wedge was 14. No complications were
encountered. Cardiac
output was 5.46 L/min. with a cardiac index of 2.5. Patient, about 1 o�clock4 that
afternoon,5 coded with
profound bradycardia and then went into ventricular tachycardia. Advanced cardiac
life support (ACLS)
was called. He continued to go into repeated episodes of ventricular tachycardia6
and ventricular
fibrillation (VF)7 with accelerated idioventricular rhythm (AIVR)8. He was
cardioverted x4, placed on
bretylium after not responding to lidocaine, received 3 ampules9 of bicarbonate10.
He was coded for a
significant length of time with no success, and the patient was finally pronounced
dead.
FINAL DIAGNOSIS11
1. Sepsis.
2. Adult respiratory distress syndrome.
3. Status post cardiac arrest and code, for unclear reasons.
1969 characters

2 Change the dictated article and to the pronoun that to provide a subject for the
verb was.
parentheses.
4 For on-the-hour expressions, it is preferable to add o�clock rather than a colon
and zeros.
5 Set off parenthetical expressions with commas.
6 �V-tach� is an unacceptable brief form and should be expanded to ventricular
tachycardia.
parentheses.
parentheses.
11 Number the diagnoses when more than one is dictated.

REASON FOR ADMISSION

Patient is an 84-year-old female with a long-standing severe congestive heart
failure history who was just
discharged from this facility after prolonged treatment for syncope, atrial
flutter, and severe congestive
heart failure. On the day of admission, the patient was admitted with acute
bronchitis complicated by
breathlessness, weakness, and extreme fatigue.
HOSPITAL COURSE
On admission hemoglobin was 11.4. Chemistry profile was unremarkable other than
serum sodium level
of 127. Subsequent to admission the patient was treated with parenteral
bronchodilators, broad-spectrum
antibiotics, and inhaled bronchodilators. EKG showed atrial fibrillation with a
controlled ventricular
response and evidence of an old anteroseptal myocardial infarction. Chest x-ray
showed some interstitial
edema and subpulmonic fluid consistent with congestive heart failure. The
patient�s overall condition was
one of initial improvement. However, the patient became hypotensive and
bradycardic and was
transferred to the intensive care unit. At that time she suffered
cardiorespiratory arrest and was unable to
be resuscitated.
FINAL DIAGNOSIS
Recurrent bronchitis superimposed on acute congestive heart failure.
CAUSE OF DEATH
Ventricular fibrillation followed by asystole.
1300 characters

CONSULTATION (4:30)
HISTORY
Patient is a 70-year-old white female, well known to me through my office, who was
admitted because a
large right pleural effusion was discovered in her right lung.1 She gives a
history of little appetite and
weight loss for the past 2-3 months and nausea and vomiting for the past 1-2
weeks. She is only able to
tolerate a liquid diet at present. She feels weak, is unsteady on her feet, and
has shortness of breath with
exertion.
PAST MEDICAL HISTORY

Patient has been a heavy smoker for many years. She2 underwent a total abdominal
hysterectomy and
bilateral salpingo-oophorectomy as well as an appendectomy and cholecystectomy.
She had a partial
gastrectomy with vagotomy for bleeding peptic ulcer disease. She had numerous
transfusions at that time.
She has had numerous spinal compression fractures secondary to osteoporosis. She
also has a history of
heavy alcohol use in the past.
ALLERGIES3
She has no known allergies.
MEDICATIONS
Present medications include Dilatrate 40 mg daily,4 Lanoxin 0.125 mg daily,
Ecotrin 5 grains5 daily, and
Ditropan 5 mg b.i.d.
VITAL SIGNS: Weight is 111, height is 56-1/2 inches.6 Blood pressure is 118/54,
pulse is 86,
respirations 18, and temperature is 96 orally.
GENERAL: She is a well-developed, cachectic, chronically ill-appearing white
female who is alert,
oriented, and resting comfortably.
HEENT:7 Head is normocephalic with no signs of trauma. Eyes: Pupils equal, round,
reactive to light
(PERRL).8 Extraocular movements intact (EOMI).9 Fundi show a cataract on the left
and an implant on
the right with no obvious funduscopic abnormalities. Ears and throat are clear.
She does have dentures
both in the upper and lower jaw.
NECK: Neck is supple with no nodes, bruits, or thyromegaly.
CHEST: Chest has decreased breath sounds on10 the right, halfway up the right
posterior lobe. No obvious
rales or rhonchi are heard.
HEART: Heart has11 regular rate and rhythm with normal S1 and S2. No S312 or
murmurs heard.
BREASTS: Breasts have some mild fibrocystic changes bilaterally, but no discrete
masses, tenderness, or
nipple discharge is noted.
ABDOMEN: Abdomen is soft, nontender, with no masses or hepatosplenomegaly.
EXTREMITIES: Extremities show no cyanosis, clubbing, edema, or deformities. Pedal
pulses are +1
bilaterally.
NEUROLOGICAL: Neurological exam is intact.

PELVIC: Pelvic exam done by me in my office 2 weeks ago showed an13 introitus with
a minimal amount
of mucosal atrophy and no sign of irritation. Vaginal vault is a blind pouch with
a surgically absent cervix
and uterus. No adnexal masses or tenderness was14 noted.
RECTAL: Rectal exam at that time also showed normal anal sphincter, normal anal
canal, no masses
along the anal verge, and stools were Hemoccult-negative.
IMPRESSION
1. Right pleural effusion.

2. Polyclonal gammopathy.
3. Chronic obstructive pulmonary disease.
4. Osteoporosis.
5. Heavy smoker.
6. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy,
appendectomy,
cholecystectomy, and partial gastrectomy with selective vagotomy for peptic ulcer
disease.
7. History of two previous cerebrovascular accidents with little residual.
8. Rule out occult lung malignancy.
PLAN
1. Patient should be on the following medications: Dilatrate 40 mg daily,15

Lanoxin 0.125 mg daily.
2. Thoracentesis will be performed.
3. CT scan of the lung and possibly of the abdomen and head will need to be done.
4. Possible bronchoscopy will also be considered.
3452 characters
1 Right lung was dictated but is incorrect. Effusion is in the pleural cavity, not
the lung.
2 Insert She as the subject of the new sentence.
4 The dictated q.d. is on the list of dangerous abbreviations and should be edited
to daily or every day.
5 The doctor misspoke and the dosage should be flagged to the dictator�s
attention.
6 It is recommended that foot and inch symbols be used only in tables.
7 Omit the dictated exam because it is unnecessary and inconsistent with other
headings.
10 The dictated in should be edited to on for correctness.
11 The dictated is should be edited to has for correctness.
12 Alternative: S1 and S2. No S3.
13 Edit the dictated a to the appropriate article an before a vowel sound.
14 Edit were to was for subject-verb agreement; in compound subjects joined by or,
the verb is determined by the
subject closest to it.
15 The dictated q.d. is on the list of dangerous abbreviations and should be
edited to daily or every day.
HISTORY AND PHYSICAL EXAMINATION1

This 70-year-old Caucasian female was admitted to the hospital with an acute adult
respiratory distress
syndrome. For details of the history and physical, see the History and Physical
form.
LABORATORY DATA
Laboratory and x-ray studies on admission are as follows: Electrocardiogram was
abnormal, showing
premature atrial complexes, right atrial enlargement, and left axis deviation with
a complete left bundle
branch block. Pulmonary function studies on admission showed an2 FVC at 34% of
predicted, FEV13 is
38% of predicted. Arterial blood gases on admission showed a pO2 of 60, pCO2 of
43, a pH of 7.42. Her
blood count showed a WBC of 11,000. Hematocrit was4 44. Hemoglobin was 14.6. There
was a normal
differential. Chloride 95, sodium of 133, a potassium of 4.5. The theophylline
level was only 6.6, which
was below the therapeutic range. Sputum cultures showed a normal respiratory
flora.
THERAPY AND HOSPITAL COURSE

She was placed at bed5 with bathroom privileges. The patient was started on
ampicillin 500 mg IV every
6 hours. Also the patient was given Hycomine. The patient was given Proventil 2 mg
3 times a day by
mouth. She was started on updraft therapy using Alupent. The patient has improved
with this regimen and
was finally discharged home. Ought to remain on her Proventil and her ampicillin
by mouth.
FINAL DIAGNOSIS
Acute adult respiratory distress syndrome.
1544 characters

3 Alternative: FEV-1. The dictated �second� means forced expiratory volume in 1
second (a unit of time) and is not
to be transcribed.
4 Edit the dictated is to was for consistency of tense.
5 Alternative: bed rest.
An 87-year-old white female with evidence of congestive heart failure. She was
begun on salt restriction,
Lasix 20 mg intramuscularly, continued on Lanoxin, and given bathroom privileges.
She diuresed well,
and the serial chest films showed evidence of improvement in her pulmonary edema.
Echocardiogram
showed aortic stenosis. She had frequent complaints of vertigo. Upper GI series
showed a small reducible
hiatal hernia. Her gallbladder was normal. The electrocardiogram showed a 1st
degree atrioventricular
(AV) block1 but was otherwise normal. Serial electrocardiograms showed atrial
fibrillation. Mild mitral
stenosis was also present on her echocardiogram. Sodium was 130. Electrolytes were
monitored.
Urinalysis2 was within the limits of normal.
Patient had converted to a sinus rhythm on the 5th, was ambulatory with effort but
dyspnea was not
marked, and her lungs had cleared. She was discharged.
FINAL DIAGNOSIS3
1. Arteriosclerotic heart disease.

2. Intermittent atrial fibrillation.
3. Aortic and mitral stenosis.
4. Pulmonary edema, grade 3.
5. Hiatal hernia with esophageal reflux.
6. Pharyngitis, acute.
She will continue on Lanoxin, diuretics, salt restriction, Antivert as necessary
for syncope, and be
followed as an outpatient. Prognosis is fair.
1265 characters
1 Alternative: AV block. AV block is a common expression and ordinarily need not

be expanded. The abbreviation
AV can stand for other terms, however, such as aortic valve and arteriovenous,
neither of which is used with �block.�
2 The combined form urinalysis should be used rather than the dictated �urine
analysis.�
3 Number the diagnoses when more than one is dictated.

CONSULTATION (6:00)
CHIEF COMPLAINT1
Patient is a 59-year-old housewife who presents with a chief complaint of
shortness of breath of about 6
weeks� duration.

The patient has a long history of ischemic cardiomyopathy. The patient is status
post myocardial
infarction. She was doing well for the past 10 years until last May, when she
experienced about 4
episodes of congestive heart failure. An episode in July was also associated with
another myocardial
infarction, and she underwent a triple-vessel coronary artery bypass graft.
Patient�s surgery was
complicated by thrombosis in the groin and persistent thoracic bleeding which
required reopening of the
chest. Patient also had a sympathectomy of the left lower extremity due to painful
left lower extremity,
and she had a fasciotomy of the left lower extremity requiring grafting. Patient
states that she has been
feeling short of breath, unable to lie flat in a bed, wakes up in the middle of
the night with shortness of
breath for the past 6 weeks. Symptoms appear to be getting worse recently. Patient
was hospitalized for
heart failure and cellulitis of the left lower extremity.
CURRENT MEDICATIONS
Patient takes Lanoxin 0.125 mg 1 tablet p.o. q.a.m.2 Patient is on Lasix 80 mg 1
tablet t.i.d.; KCl 60 mEq
p.o. b.i.d.; Glucotrol 5 mg 2 tablets p.o. q.a.m.3 and 1 tablet q.p.m.4; and
Persantine 50 mg 1 tablet p.o.
b.i.d. Patient is also on Valium 5 mg 1 tablet p.o. p.r.n., and Percocet 1 tablet
p.o. p.r.n.
SOCIAL HISTORY
Patient smoked 2 packs per day for 40 years. Patient drinks alcohol occasionally.
Drinks 2 cups of coffee
per day.
FAMILY HISTORY
Father died in his 60s5 of a heart attack. Mother died at age 53 of cerebral
hemorrhage. Mother also had a
history of diabetes. A sister died at age 53 of cancer of the colon, and a brother
is 57 and he is in good
health. He has high blood pressure.

She is status post dilatation and curettage (D&C)6 and history of diabetes
mellitus for 3 years. History of
high blood pressure for 30 years. Patient is dependent on narcotics and anxiolytic
agents including
Valium and Tranxene. The patient is status post coronary artery bypass graft,
status post sympathectomy,
status post fasciotomy of the left lower leg.
REVIEW OF SYSTEMS
Noncontributory.

VITAL SIGNS: Blood pressure is 132/76, pulse 114 and regular, respirations 20 and
regular, temperature
97�.
GENERAL: Patient is alert and oriented x3. Patient is sitting up quietly in bed in
mild respiratory distress.
Nonicteric.
HEENT: Pupils are equal, reactive, round, and accommodate.8 Extraocular muscles
were intact. Cranial
nerves 2-12 were within normal limits. Funduscopy reveals9 poorly visualized
retinas,10 but there were11
no hemorrhages, no papilledema noted.
NECK: Patient had jugular venous distention at 30�. There were12 no carotid
bruits. No thyromegaly was
noted.
RESPIRATORY: Bilateral rales about one-third the way up from the bases. The bases
were dull to
percussion.
HEART: S1, S2.13 A14 1/6 systolic murmur was noted at the apex. S315 gallop was
also heard.
ABDOMEN: Abdomen was obese. Bowel sounds were normal. Scar in the left upper
quadrant and left
flank. Nontender.
RECTAL: Rectal exam was refused.
PELVIC: Pelvic exam was also refused by the patient.
EXTREMITIES: A16 3+ pitting edema of the left leg, and 2+ pitting edema of the
right leg extending up
to the hips. Patient also has pitting edema of the dependent areas of the back.
NEUROLOGIC:17 Motor and sensory functions were grossly intact. Patient has a
depression over the left
lateral lower leg, and the right big toe is black at its tip.
LABORATORY RESULTS
Sodium is 136, potassium 4.0, chloride 94, CO2 32. Glucose 149. BUN 14, creatinine
1.2. Urinalysis
shows a hematuria of 30-40 RBC/hpf.18 White blood cell count per high-power
field19 was 7-8 with 1+
bacteria. Digoxin level was 1.58.
IMPRESSION20
1. Ischemic cardiomyopathy.
2. Type 2 diabetes mellitus.
3. Cellulitis, left lower extremity.
4. Hypertension.
5. Hyperlipidemia.
6. Obesity.
7. Narcotics dependence.
8. Status post sympathectomy.
9. Status post dilatation and curettage (D&C).21
PLAN
To continue dobutamine and captopril 12.5 mg 1 tablet p.o. q.12 h.,22 and keep the
patient on Accu-Cheks
q.i.d. Obtain a mental health consult for patient�s dependence on narcotics and
anxiolytics.
Thanks again for the consultation.
4355 characters

2 Alternative: every morning.
4 Alternative: every evening.
5 Use numerals plus s to refer to decades; do not use an apostrophe.
6 Expand an abbreviation on its first use and place abbreviation within
parentheses.
8 Edit accommodates to accommodate for subject-verb agreement (�Pupils . . .
accommodate.�
9 Edit the dictated reviews to reveals for accuracy.
10 Edit retina to plural retinas since both retinas were examined.
11 Edit was to were for proper subject-verb agreement (�no hemorrhages were
there�).
12 Edit the dictated are to were for proper tense.
13 Alternative: S1, S2.
14 Insert the article A to avoid beginning the sentence with a numeral.
15 Alternative: S3.
16 Spell out numbers beginning a sentence or recast the sentence: �Three plus
pitting edema . . . ,� or insert �A� or
�There is a . . .�
17 Neuro was expanded as a heading, and it is not necessary to use the word exam
in a subheading.
18 The dictator says �RBC per high-power field.� Since �RBC� is abbreviated,
�high-power field� may be
abbreviated as well, and a virgule (/) used to separate the abbreviations.
19 The dictator says �white blood cell count� in full (rather than abbreviating it
to WBC) so it is proper to write out
high-power field as well.
20 Diagnoses are numbered when there are more than one.
21 Expand an abbreviation in the diagnosis or impression.
22 Alternative: every 12 hours.

HISTORY1
A 52-year-old female who has been seen frequently during the past several months,
mainly with problems
related to respiratory tract with shortness of breath, wheezing, and repeated
infections. The patient has
been hospitalized several times. When hospitalized, the patient was found to have
a supraventricular
tachycardia, responding partially to verapamil and Lanoxin. She has continued on
these medicines. On the
day of admission the patient came to the emergency room because of severe cough
and fever. Chest x-ray
showed evidence of pneumonia. The patient was admitted for this reason. Pertinent
to the patient�s
problems is the fact she has continued to smoke approximately 2 packs a day
despite her many illnesses
and repeated instructions to stop.
LABORATORY2 STUDIES
Blood cultures on 3 occasions were reported as no growth. Sputum culture was3
reported as normal flora.
Culture was ordered when the patient developed cough productive of yellow sputum.
The hospital was
instructed to place a report on the chart in regard4 to this culture; there5 is
not a report on the chart.
Urinalysis on admission showed 15-20 RBCs. Repeat urinalysis was essentially
unremarkable. Dipstick
did show trace Hematest-positive. CPK was within normal range. Theophylline level
was done on several
occasions and was below therapeutic range. Chemistry profile was done on 2
occasions and was abnormal
in several parameters: glucose, creatinine, calcium, proteins, triglycerides, and
cholesterol, none of which
appeared significant. CBC showed white count in normal range and a hemoglobin
decreased at 10.4,
hematocrit 31.2. Chest x-ray was interpreted as �Unremarkable chest except for
some suggestion of
chronic bronchitis within the right infrahilar region. No change in appearance of
chest since examination
2 days ago.� IVP was reported as �Normal intravenous pyelogram except for partial
right upper pole
nephrectomy.�6 EKG reported as �Abnormal electrocardiogram showing low-voltage
changes suggestive
of anterior septal7 myocardial infarction with ST-T abnormalities.�
COURSE IN HOSPITAL
The patient was treated with antiemetics, IV fluids, Claforan, nasal oxygen,
Alupent by intermittent
positive pressure breathing (IPPB).8 Placebo was prescribed for pain,9 along with
morphine, the placebo
sometimes working as well as the morphine. She was continued on her previous
medications of verapamil
and Lanoxin, and her heart did not appear to be a significant problem in her
illness. The patient continued
to have a wracking cough productive of copious amounts of thick sputum. She
complained bitterly of pain
in the back and lower chest and felt she needed something for nerves. She asked
for Valium by name. In
the past, several antidepressants and tranquilizers were prescribed per the
patient�s request. The IV
medications were discontinued. The patient had been receiving Claforan, and this
had been changed to
Rocephin. In addition she was receiving Solu-Cortef. This was changed to
prednisone. Flexeril was
prescribed as a muscle relaxant. This was discontinued when her husband reported
the patient did not
tolerate the medication and later �climbed the walls.�
DISPOSITION
The patient is to return to her home that she shares with her husband. Again there
was a long discussion
about her not smoking. She is to continue Cipro 500 mg b.i.d., Atrovent 2 sprays
q.6 h.10 p.r.n. wheezing.

She is to continue Lanoxin 0.25 mg daily, verapamil 80 mg t.i.d., and Choledyl 400
mg t.i.d. She is to be
seen in the office Wednesday. CBC will be repeated then.
DISCHARGE DIAGNOSIS11
1. Right lower lobe pneumonia.

2. Emphysema.
3. Cardiac arrhythmia.
Improved. Stable.
3734 characters

3 Edit were to was for proper subject-verb agreement; there was only one culture.
4 Edit regards to regard for correct usage.
5 Alternative punctuation: culture. There . . .
6 Add ending quotation marks.
7 Alternative: anteroseptal.
parentheses.
9 A comma here is essential for medical meaning. Otherwise, it would appear that
the placebo was prescribed for
pain and morphine.
10 Alternative: every 6 hours.
11 Number the diagnoses.

Patient is a 67-year-old male with no prior cardiac history who was admitted with
acute anterior
myocardial infarction. He also has a history of hypertension. Patient underwent
left heart catheterization,
coronary arteriography, and left ventricular angiography which revealed single-
vessel disease with tight
obstruction of the left anterior descending (LAD), relatively normal left
ventricular function despite
evidence of an acute anterior wall myocardial infarction. Patient underwent an
exercise tolerance test
under the Naughton protocol, exercising 14 minutes, with accentuation of ST-
segment elevation
anteriorly. He had no symptoms and no arrhythmia. Because of the dramatic ST-
segment change
suggesting continued ischemia, patient was recommended for percutaneous
transluminal coronary
angioplasty (PTCA).1 Patient was transferred for PTCA.
Discharge medications included Minipress 2 mg daily,2 Ecotrin 1 tablet a day,

nitroglycerin 1/150 p.r.n.
DISCHARGE DIAGNOSIS
Status post anterior wall myocardial infarction with postinfarction coronary
insufficiency and coronary
disease.
1110 characters

parentheses.
2
Edit q.d. to daily to avoid using a dangerous abbreviation.

DISCHARGE DIAGNOSES
1.
Pulmonary edema.
2.
Atrial fibrillation that has resolved.
3.
Alcoholism.
4.
Status post Haemophilus influenzae bronchitis.
5.
Small subdural hematoma that required no surgical intervention.
6.
Chronic dementia, probably Alzheimer�s1 disease type, with superimposed delirium
during the
hospitalization that has now resolved.
HOSPITAL COURSE
This patient was originally admitted to the intensive care unit. She was found to
be in pulmonary edema
and given diuretics. She had episodes of atrial fibrillation which were treated
with digoxin and Lopressor.
During the hospitalization she developed a fever and productive cough which was
cultured for
Haemophilus influenzae. She was treated with ciprofloxacin for approximately 14
days. The bronchitis
has entirely resolved. Her congestive heart failure also resolved as well as the
atrial fibrillation. I
originally met the patient in the intensive care unit. The patient was extremely
confused. Her confusion
waxed and waned during the period of a day. There were times when she was more
lucid than other times.
She had been placed on Librium because of a concern for developing delirium
tremens. She had a strong
history of alcohol abuse. The Librium was discontinued, and the patient was given
thiamine
intramuscularly.
A CT scan was obtained which showed a chronic right subdural hematoma with a
minimal midline shift
of2 2-3 mm. Due to the small size of the subdural, it was not clinically
significant, and3 surgery was not
indicated. Her RPR was nonreactive. Her PT was 10.5 and PTT 27.9. Her last
hemoglobin showed a level
of 12.9 with a white count of 8900 and MCV of 102.6. For that reason, B124 and
folic acid levels were
obtained and are still pending. The latest SMAC showed a normal glucose of 88. Her
BUN was 28 with a
creatinine 0.7. Her sodium was a little low at 130. Potassium 4.9. Her liver
function tests showed that her
SGOT was 15, the alkaline phosphatase was 76, total bilirubin was 0.7,5 all of
which are normal. A serum
ammonia level was obtained which was 30 and normal. Her thyroid tests were done
which showed a
normal T4 of 8.9. The TSH was 1.6, which is also normal. A digoxin blood level was
done and was found
to be 1.0. Cardiac enzymes showed no evidence of myocardial injury. The most
recent EKG showed
nonspecific ST-T wave abnormalities and a left ventricular hypertrophy. She was in
sinus rhythm. The
original chest x-ray showed pulmonary edema. It was repeated and showed mild
pulmonary edema. The
patient had developed small pleural effusions.
The patient�s medical status improved. Her mental status also improved. She
continued to eat better. She
increased her activity and, in fact, wandered all over the hospital. Her delirium
cleared, but her underlying
chronic dementia remained. The patient was generally confused and often not
oriented to place or time.
Her at-times belligerent behavior gave way to a much more pleasant disposition.
The patient was
discharged to a nursing home. I anticipate that she will be chronically confused
from her presumed

Alzheimer�s disease and that her dementia will become progressively worse over the
years. She is to
refrain from cigarette smoking and from alcohol intake. Activity as tolerated.
Diet regular. No extra salt.
MEDICATIONS
Digoxin 0.25 mg daily,6 Lopressor 50 mg daily, Isordil 10 mg q.6 h., and Haldol
0.5 mg p.o. b.i.d. p.r.n.
aggressive behavior.
3418 characters

2 The dictator says �to 2-3 mm.�
3 Edit or to and for proper usage. Alternative: significant nor was surgery
indicated.
4 Alternative: B12.
5 The dictator dictated �point seven.� Place a zero before the decimal in values
of less than 1.
6 Edit q.d. to daily to avoid using a dangerous abbreviation.

HISTORY AND PHYSICAL (3:00)
BRIEF PREOPERATIVE HISTORY

Patient is a 48-year-old white male who was admitted with sudden onset of severe
chest pain. At that time
his cardiac enzymes were negative, and he was urgently taken to the coronary
angiogram suite, and the
study revealed severe 3-vessel disease with 90% left main stenosis.

Patient�s past medical history was significant for diabetes mellitus,
hypertension, depression, hepatitis,
coronary artery disease. He had had a coronary angiogram 5 years ago which showed
blockage in his
coronary arteries. Patient was placed on heparin drip and transferred to the
hospital for urgent
revascularization. At the time of his admission, patient did not have any chest
pain. His coronary
angiogram revealed 90% left main disease, 90% proximal left anterior descending
(LAD)2 stenosis, 90%
stenosis at the origin of the ramus intermedius, 90% stenosis at the origin of the
left circumflex coronary
artery, and 99% mid right coronary artery stenosis. The collateral circulation
from the left side was filling
the posterior descending artery (PDA).3 His left ventricular ejection fraction was
approximately 50%.
Patient�s past surgical history was significant for hernia repair,
cholecystectomy, cardiac catheterization.
Patient had quit smoking 6 years ago and denied any alcohol abuse.
GENERAL: On examination he was an obese white male in no acute distress, on
heparin drip, and he was
awake, alert, and oriented.
VITAL SIGNS: He was afebrile. Heart rate was 80 per minute, and blood pressure was
140/80 mmHg.
NECK: His neck was supple. There were no carotid bruits.
CHEST: Air entry was equal bilaterally, and heart was regular.
ABDOMEN: Abdomen was obese. There were no bruits.
EXTREMITIES: Extremities had intact pulses.
LABORATORY DATA
Patient�s hemoglobin was 14.5 g/dL, and platelet count was 262. His creatinine was
0.8 mg/dL.
IMPRESSION
Patient was admitted with unstable angina with severe 3-vessel coronary artery
disease with left main
stenosis with slightly decreased left ventricular ejection fraction, and he was
offered an urgent coronary
artery bypass grafting. The risks of the operation, which included but were not
limited to infection,
bleeding, perioperative myocardial infarction and stroke, pulmonary or renal
failure, possible death, were
discussed with the patient and his relatives, and he opted for surgery and wanted
us to proceed.
2440 characters

parentheses.
parentheses. PDA can also stand for patent
ductus arteriosus.

OFFICE NOTE (0:30)
While being observed after his cardioversion, he1 went back into atrial flutter
with 4:1 block with a rate in
the 70s. His quinidine was therefore discontinued, and the digoxin was increased
to 0.25 mg per day, as
well as the Lasix and potassium. We plan to see him in 1 week to be sure that his
heart rate is under
control. If not, a tiny dose of Inderal may be added. Also, he will have a serum
potassium, BUN,
creatinine, and digoxin level done in 1 week.
475 characters
1
Insert the pronoun he
to complete the sentence.

SOAP NOTE (2:30)
SUBJECTIVE
Patient is a 77-year-old white female whom1 I am following status post
hospitalization for severe chronic
obstructive pulmonary disease (COPD)2, status post myocardial infarction (MI)3.
She was brought in by
her daughter and granddaughter, who both4 state the patient has had no change in
her physical condition
since the last visit. They state she is using her oxygen 2 L via nasal cannula
virtually all the time. Has had
no increase in shortness of breath, no increase in her chronic cough, and no fever
or chills. They state that
the antibiotic that was called in approximately 3 weeks ago was only taken for 1
day and that it made the
patient sicker, so she has not taken it since. She at this time continues on her
Ventolin inhaler 2 puffs
q.i.d., her TheoDur 200 mg t.i.d, her Cardizem 30 mg t.i.d., and Zantac 150 mg
b.i.d. She has tapered off
her prednisone and has not taken this for approximately 2 weeks. She does continue
to smoke but has cut
down to approximately 1 pack lasting 3 days. States she does turn her oxygen off
when she smokes.
Patient�s only complaint is some mild posterior back pain.
OBJECTIVE
Temperature is 99.0, pulse 100, respirations 40. The heart has a regular rate and
rhythm with a 3/6
systolic ejection murmur. There is no S35 heard. The lungs are clear anteriorly
although some upper
airway sounds are heard. There is decreased flow in the posterior lung fields. The
abdomen is soft,
nontender. The bowel sounds are positive. Skin shows generalized thinning with
several small areas of
healing ulcerations over the feet and hands. There is also 1-2+6 pitting edema in
the lower extremities and
trace edema in the right hand.
ASSESSMENT
1. Severe chronic obstructive pulmonary disease (COPD).7

2. Status post myocardial infarction (MI).8
3. Peripheral vascular disease.
4. Smoker.
PLAN
I will obtain a theophylline level today. I will also add Atrovent inhaler 2 puffs
q.6 hours,9 which the
patient is to use between her Ventolin inhaler use. Patient was instructed once
again to obtain T.E.D.10
hose, which she has not11 yet, to see if this will help with the leg swelling. It
was considered12 that a bit of
heart failure could be contributing to the edema, but at this time we will not
obtain an echocardiogram,
but we will consider it if the T.E.D.13 hose do not control the swelling. A
urinalysis (UA)14 was obtained
due to patient�s right costovertebral angle (CVA)15 pain, and the dipstick was
negative except trace for
protein. Will continue to follow the patient with Home Health Care, and I will see
her again in 1 month in
my clinic. She is to call in if there are any acute changes between now and then.
2747 characters

1 Edit who to whom for grammatical correctness (�I am following whom�).
2 Expand an abbreviation on its first use and place the abbreviation within
parentheses.
parentheses.
4 Edit �both who state� to �who both state� or �both of whom state� for proper
construction.
5 Alternative: S3.
6 Alternative: 1 to 2+, 1+ to 2+.
7 Expand an abbreviation in a diagnosis and place the abbreviation within
parentheses.
8 Expand an abbreviation in a diagnosis and place the abbreviation within
parentheses.
10 T.E.D. (with periods) is a trademarked term.
11 Expand contractions except in direct quotations.
12 Editing to correct awkward dictation. Delete �the fact.�
13 T.E.D. (with periods) is a trademarked product.
14 The combined form urinalysis should be used rather than the dictated �urine
analysis.� �UA� is commonly used in
a Laboratory Data paragraph, but elsewhere in a report, it is preferable to expand
it.
parentheses.

ELECTROCARDIOGRAM RHYTHM STRIP (2125 HOURS) (0:30)
Atrial rate 125.1 PR interval 0.16.2 Ventricular rate 125. QRS 0.08.3 No axis
deviation.4 Rhythm: Sinus
tachycardia with T-wave inversions in leads III and aVF, which was present on the
previous EKG.
IMPRESSION
Abnormal electrocardiogram.5 Sinus tachycardia.
309 characters
1 The values dictated in an EKG narrative are sometimes typed on a preprinted form
or into a template.
2 The dictator says �point one six.� Add a zero before the decimal for values
under 1.
3 The dictator says �point zero eight.� Add a zero before the decimal for values
under 1.
4 Edit the incorrect term �normal axis deviation� to no axis deviation or normal
axis. Axis deviation is a shift from
the normal axis.
5 Expand abbreviations used in the diagnosis.

FINAL DIAGNOSIS
1. Malnutrition and dehydration.

2. Chronic alcoholism.
3. Severe metabolic encephalopathy.
4. Severe chronic obstructive pulmonary disease with pulmonary fibrosis and
emphysema.
5. Ischemic cardiomyopathy.
6. Urinary tract infection.1
HISTORY
This is a 65-year-old male who was admitted because of progressive weakness,
anorexia, shortness of
breath related to a marked increase in his alcohol2 intake. Past history included
hypertension, coronary
disease, arteriosclerotic peripheral vascular disease (ASPVD),3 and chronic
obstructive pulmonary
disease.
Physical examination revealed an extremely weak, lethargic male with evidence of
hyperinflation of his
chest, systolic ejection murmur, slight hepatomegaly, and extreme muscle weakness
and wasting. He had
multiple linear excoriations on his forearms and some ecchymoses on his abdominal
wall as well.
LABORATORY DATA
Chest x-ray showed mild pulmonary fibrosis and overexpansion. Chest x-ray on March
95 showed no
significant change with normal-sized heart. Ultrasound of the gallbladder revealed
biliary sludge. CT scan
of the brain revealed cerebral atrophy. Chest x-ray March 15 revealed some new
basilar infiltrates
bilaterally. EEG was abnormal with subtle generalized slowing. Hepatitis antigens
showed an HBsAg was
reactive, and the rest were all negative. On March 9, ABG showed a pO2 of 48, pH
of 7.52, and a pCO26
of 34. Sodium of 159, potassium of 3.0, chloride of 114, BUN of 36, creatinine of
1, and a blood sugar of
166. Ammonia level was 46�normal. White count on March 7 was 12.3 with slight left
shift. On March
16 the white count was 24,000, hemoglobin of 10, hematocrit of 30, and a marked
left shift. Macrocytosis
was present throughout. Pro time7 was 11.5 seconds on March 7. The sodium
gradually decreased from
159 down to 135 by March 13, and the blood sugar decreased8 from 166 to 97. The
potassiums ranged
from 3 to 3.9. Chemistry profile showed a cholesterol of 138, total bilirubin 1.7,
LDH of 231, and a
normal alkaline phosphatase. Liver profile on March 9 showed a GGT of 264 with
normal total bilirubin.
Serum cortisol on March 14 was 21.5�normal. Urinalysis on March 17 revealed pyuria
and bacteriuria.
Several blood cultures were negative. Gram stain of the sputum revealed
Haemophilus influenzae. Urine
510
culture grew out Streptococcus faecalis9

greater than 10 colony count.
HOSPITAL COURSE
Patient admitted with acute and chronic alcoholism with dehydration and11
debilitation. He was placed on
hydration, given supplemental potassium for his hypokalemia. He had continuous
upper respiratory
noises with creamy sputum, with difficulty expectorating because of his weakened
state. Chest x-rays

initially were continually negative. He had no asterixis and a normal serum
ammonia. He spiked fevers up
to 104 of undetermined source with a negative urine on admission and a negative
chest x-ray. He did
become slightly12 more alert and had no nuchal rigidity. Patient continued to be
very lethargic although
oriented, and at times was combative and agitated. His dehydration did seem to
improve with decrease of
his azotemia. He had a nasogastric tube inserted13 when he had some vomiting, and
that gradually was
clamped and removed. He was seen in consultation for gastroenterology reasons, and
it was14 felt that he
had alcoholic liver disease. Because of his nutritional aspect, metabolic support
team also saw him.
Because of his failure to improve, a neurology consult was done with the
possibility that he had an
alcohol neurological syndrome, perhaps partially treated. Serum cortisol was done,
and that was normal.
He did have increase15 in his temperature, and he was treated with antibiotics,
and chest x-ray perhaps had
suggested some hypostatic changes with some bibasilar infiltrates. He was treated
for a possible
Wernicke�s,16 but he had no change in his mental status. He did have a
leukocytosis, but his temperature
was down. He perhaps had hepatic encephalopathy with a slowing of his EEG waves,
and all that could
be done was to continue thiamine and correct any metabolic derangements, which was
being done.
However, on March 18, the patient was found deceased without vital signs.
4210 characters
1 Correct dictated number 7 to 6.

2 Edit alcoholic to noun form for proper word usage.
3 Expand abbreviation on first use and place abbreviation within parentheses.
4 Add headings for consistency in format.
5 Alternative: 3/9. It is preferable to spell out dates used in the body of a
report, writing out the name of the month
and using four digits for the year (if known). However, if dates are used
repeatedly, as in a long history or hospital
course, they may be expressed as numerals separated by virgules or hyphens as long
as they are clearly understood.
Because of the numerous lab values in this paragraph, it is felt that writing out
the dates would be preferable.
6 Alternative: PO2, PCO2 or PO2, PCO2.
7 The expanded form, prothrombin time, is preferable; if the short form is
dictated, it should be written as two
words: pro time.
8 Edit decreasing to decreased for correct verb tense.
9 Expand abbreviated names of bacteria on first use.
10 Alternative: 10 to the 5th colony count.
11 Insert and because there are only 2 items and not a series.
12 Move slightly so that it precedes the word it modifies.
13 Edit the dictated implanted to inserted to correct the dictator�s slip of the
tongue. Devices are implanted under the
skin but inserted into body cavities. On the job this discrepancy would be flagged
to the dictator�s attention.
14 This edit is necessary because otherwise the verb �felt� appears to go with
�patient,� the subject of the first clause.
15 Edit the dictated decrease to increase to correct the dictator�s error. All
indications are that the temperature
increased, not decreased. On the job this discrepancy would be flagged to the
dictator�s attention.
16 Although the possessive may be dropped from eponyms used as adjectives, it is
retained when the eponym is not
accompanied by the noun.


A man, 68 years of age, with the sudden onset of cardiac asystole or ventricular
fibrillation, no blood
pressure, no pulse, and was coded at the scene, and then some semblance of a
rhythm was obtained, and it
was felt that he either had ventricular tachycardia or supraventricular
tachycardia.2 Lidocaine was started
in the cardiac care unit. Diagnosis at the time was the fact that he had had
another myocardial infarct with
a fatal arrhythmia, probably now has brain damage due to the fact he probably was
down more than 5
minutes, and neurological examination that seems to indicate that he does indeed
have rather severe brain
damage.
PAST HISTORY
His past history revealed that he has had a cardiac history before in that he has
had a myocardial infarct.
Also has had liver disease in that he has had some changes on his chemistry
profile in the office and was
cautioned about this. He did admit to the fact that he was drinking a little bit
heavier than he was
supposed to be. This was about a year or 2 years ago, and he really did not3 do
too much on trying to
improve this situation.
Cardiac enzymes revealed that he did indeed have an MB band and also that his
number 3 set of LDH
enzymes showed that number 1 was higher than number 2.
FAMILY HISTORY
Noncontributory.
SOCIAL HISTORY
He was drinking, as already mentioned. He did not smoke.
ALLERGIES
He had no known allergies.
VITAL SIGNS: On physical examination, his rhythm was one of probably
supraventricular tachycardia.
Rate was around 110. He did have left bundle branch block on the cardiogram.
HEENT: His HEENT revealed4 that he had some neck vein distention. He was cyanotic
about the face.
CHEST: Some rales in both bases.
HEART: Heart was rapid with probably supraventricular tachycardia.
ABDOMEN: Negative.
EXTREMITIES: Extremities were somewhat mottled.
NEUROLOGIC: Neurological examination revealed that he did not5 have any kind of
reflexes and that
pupils were about 2 mm and not responsive.

IMPRESSION
The impression on admission was that he had a cardiac arrest with arteriosclerotic
heart disease,
ventricular fibrillation, and ventricular tachycardia and a supraventricular
tachycardia, and also seems to
have brain damage from this particular episode.
His outlook is guarded and a poor prognosis.
2339 characters

2 This long sentence is transcribed as dictated in the physician�s stream-of-
consciousness style, but it is acceptable to
divide it into several complete sentences.
Alternative: HEENT: He had some �


CONSULTATION (3:30)
REASON FOR REQUEST

Pulmonary evaluation of chest pain. Patient�s chest pain can be totally reproduced
by compression of the
costochondral junctions, suggesting that she has costochondritis. Other problem
areas that need to be
explored include a possible mitral valve prolapse murmur, questionable
pneumopericardium, questionable
left paratracheal mass.
RECOMMENDATIONS
As per our discussion, would continue with the Tylenol with Codeine. Will add
local heat to the sternal
area. An echocardiogram will be requested since, in the presence of mitral valve
prolapse, she may need
antibiotic coverage at the time of her delivery. Will recheck chest x-ray to
determine whether or not the
changes noted on the emergency room film were artifact or reality. If there is
still a question, she may
require a further workup which, when possible, would include a CAT scan of the
chest and a barium
esophagram.
HISTORY1
The patient is a 17-year-old white lady who, about 2 days prior to admission,
noted the acute onset of a
sharp chest pain. It awoke her from a sleep and was associated with respirations
but not with body
position otherwise, except when she would raise her arms over her head. Meals
apparently did not
aggravate the pain.
The patient was not appreciably short of breath, but rather it hurt her to take a
deep breath, as noted. No
other specific constitutional complaints are related except for persistence of
dysphagia in the sense that,
unless she chews her food exceedingly well, it appears that the food hangs up
about midesophagus. There
is no history of pulmonary disease in the past. Her past history in general
otherwise is unremarkable. She
has allergies to aspirin and lemons. The aspirin appears to give her a sore throat
apparently secondary to
her difficulty in swallowing pills. The lemons cause her mouth to break out.
MEDICATIONS2
She apparently has been on no medications.
FAMILY HISTORY
Family history essentially unremarkable.
SOCIAL HISTORY
Social history, beyond her smoking history, appears to be negative.
REVIEW OF SYSTEMS
Review of systems otherwise is unremarkable.

GENERAL: Physical exam reveals a well-developed and nourished white lady in no
acute distress.
NECK: No masses are palpable in the neck or supraclavicular fossa.3
CHEST: Chest reveals exquisite point tenderness over the costochondral junctions
bilaterally.
LUNGS: Lungs reveal clear breath sounds bilaterally.
COR:4 Cor exam has a regular tachycardia at 110 beats per minute without gallops
audible. There is a
midsystolic click and a grade 2/6 crescendo-decrescendo systolic murmur heard best
over the left back.
EXTREMITIES: There is no obvious cyanosis, clubbing, or edema.
LABORATORY DATA5
Chest x-ray reveals no focal infiltrates. The cardiac margin is very crisp,
suggesting a possible air
interface. No obvious pericardial reflection is seen suggesting obvious
pneumopericardium. In the left
paratracheal region just superior to the carina, there appears to be a density
noted there deviating the
trachea somewhat. This is in the face of a well-oriented PA film. Arterial blood
gas on room air reveals a
somewhat compensated hyperventilation pattern. CBC has a white count of 23,000.
Hemoglobin and
hematocrit are 11 and 32, respectively. Urinalysis has TNTC6 white cells, 3-5 red
cells, trace bacteria.
Thank you for allowing us to see the patient. Will follow with you and make
further recommendations.
3425 characters
1 Because a full physical examination is dictated later, that portion of the

heading was deleted.
3 Edit to a plural form of fossa. There are two fossas (or fossae), one on each
side (above each clavicle).
4 Cor is the Latin word for heart and is frequently dictated.
6 TNTC (too numerous to count) is commonly used in laboratory data and need not be
translated.

DERMATOLOGY/PLASTICS REPORT #1
EMERGENCY DEPARTMENT REPORT (1:00)
CHIEF COMPLAINT
Laceration, right index finger.
HISTORY
This 28-year-old woman was at work 1 hour ago when she cut the tip of her right
index finger on a meat
slicer accidentally.1 She has no other injury.
The patient has a 1-inch linear longitudinal laceration over the volar aspect of
the distal phalanx, right
index finger. The patient has good sensation and vascular refill distally. There
is no deformity or
limitation of motion.
COURSE IN EMERGENCY DEPARTMENT

The patient was given a diphtheria-tetanus injection since her last shot was more
than 5 years ago. The
right index finger was anesthetized with a digital nerve block utilizing 7 mL2 of
1% plain Xylocaine. The
laceration was closed with 4-0 nylon, following vigorous Betadine prep. The digit
was then dressed with
Neosporin and tube gauze.3 The patient was given a note to return to work and keep
her finger dry.
DIAGNOSIS
Acute laceration, right index finger.
971 characters
1 Alternative, to correct misplaced modifier accidentally: This 28-year-old woman

was at work 1 hour ago when she
accidentally cut . . .
3 When a transcriptionist cannot determine if a generic or trade name is meant, it
is safer to transcribe the generic
name. Alternative: Tubegauz.

LETTER (1:30)
Dear Doctor:
Thank you for your kind referral of your patient. This lovely 32-year-old lady
presents with complaints
regarding saddlebag deformities.
On physical examination the patient showed evidence of a typical hourglass figure

with significant
saddlebag deformity, with the right being greater than the left by as much as
three-quarters of an inch.1
She is presently 5 feet 5 inches2 and weighs 146 pounds. She is within 20 pounds
of her ideal weight, and
the patient does not elect to lose any weight at the present time. Adipose
evaluation of the waist versus the
lateral thighs reveals 1 cm at the3 waist by pinch test with 6-7 cm pinch test
thigh evaluation. The patient
also shows evidence of a double-bubble deformity along the right infragluteal fold
and also has
lipodystrophy of the bilateral hips in the presacral area. However, the patient is
only concerned about the
significant saddlebag deformity which is indeed making it very difficult for the
patient to wear any
bathing attire, straight skirts, or pants.
I discussed in detail the pros and cons of suction lipectomy with this patient and
feel that she is an
excellent candidate for this procedure. She is presently trying to make a decision
as to whether she will
undergo this elective procedure.
Thank you again for allowing me to evaluate your patient regarding suction-
assisted lipectomy.
Sincerely yours,
1381 characters
1 Spell out fractional measurements that are less than one when they do not
precede a noun.
2 Write out nonmetric units of measure (foot, inch); do not use the symbols for
foot and inch. Do not place a comma
between units of the same dimension.
3 Add �at the� for accuracy. The patient does not have a �1-cm waist.�

OFFICE NOTE (0:30)
Patient brought in specimen from right upper lip. She has had this lesion many
years. It comes and goes.
She states this recently broke off and now has the specimen here. Am reluctant to
do a biopsy because
patient has allergy to lidocaine and Novocain, causing hypotension and cardiac
arrest, and do not know
exactly what to infiltrate lesion with to do shave biopsy.
ASSESSMENT
Specimen for pathology. Rule out basal cell carcinoma (BCC).1
PLAN
Will follow up on path report.
491 characters

parentheses.

OFFICE NOTE (0:30)
SUBJECTIVE1
A 6-month-old Hispanic male recently treated for atopic dermatitis and was
prescribed 1% hydrocortisone
cream. Patient is here for recheck.
HEENT: Ears are clear without significant erythema or abnormality today. Throat is
without erythema or
tonsillar enlargement.
SKIN: Rash is largely resolved on the cheeks bilaterally. He has a very small
amount of erythema there
today.
LUNGS: Lungs are clear to auscultation.
CARDIAC: Regular rate and rhythm without murmur. He has no diaper rash today.
ASSESSMENT
Atopic dermatitis, improved with 1% hydrocortisone.
PLAN
Will see him back in 2 months for his 9-month checkup. He is up-to-date on his
immunizations.
700 characters

OFFICE NOTE (1:00)
SUBJECTIVE
Patient complains of acne that she has noted over the last several months and is
not responding to Oxy 10.
OBJECTIVE
Pharynx without erythema or exudates. Neck supple. Bilateral cervical
lymphadenopathy noted,
nontender to palpation. Lungs clear to auscultation bilaterally. Heart: Regular
rate and rhythm without
murmur. Abdomen soft, nontender, nondistended. No masses noted. Normal active
bowel sounds. Skin:
Multiple pustules noted in the temple region and also on the forehead. No cysts
noted.
ASSESSMENT
1. Acne vulgaris.
2. Viral pharyngitis.
3. Upper respiratory infection (URI).1
PLAN
Erythromycin 2% solution b.i.d., Retin-A gel 0.1% applied nightly.2 She is to
start using every other day
and increase to nightly3 if her skin tolerates it. Also have recommended Dove soap
as well as
noncomedogenic makeup products. Supportive care for the URI.
875 characters
1 Expand an abbreviation on first use in the body of the report or in the

diagnosis and place the abbreviation within
parentheses.
2 The dictator says �q.h.s.,� which is on the list of dangerous abbreviations, and
should be replaced with nightly.
should be replaced with nightly.

OFFICE NOTE (0:30)
The patient was noted to have a large hyperpigmented nevus of the right breast
just at the interface of the
areola with the skin margin at the lower outer quadrant of the breast. This lesion
measured 0.8 x 0.6 cm,1
and a question of a malignant melanoma or atypia was raised due to the appearance
of the lesion. It was
recommended to the patient that this lesion be removed for permanent pathology as
well as a resection of
an additional suspicious lesion along the right upper abdomen which measured 0.3 x
0.3 cm.2
533 characters
1 The dictator says �point 8 by point 6.� Add a zero before the decimal for values
under 1, and use the symbol x for
�by.�
2 The dictator says �point 3 by point 3.� Add a zero before the decimal for values
under 1, and use the symbol x for
�by.�

LETTER (2:00)
Gentlemen:
At the request of my patient, I am forwarding this brief medical report.
HISTORY
This patient, a 30-year-old woman, gravida 0, was seen in consultation regarding
problems referable to
her massive, pendulous breasts. The patient has complaints that the breasts are
increasingly
uncomfortable and that she is experiencing tenderness and soreness in both
breasts. She gives history of
having cysts discovered in her left breast by mammography. The breasts have become
so massive that she
is experiencing a torsion and pull against her neck, shoulders, and upper back.
Her bra straps are
indenting her shoulders. She has observed secretions from her left nipple. She
wears a double-E1 cup bra.
Her height is 5 feet 2 inches2 and her weight 142 pounds.
EXAMINATION
The patient presents with massive, pendulous breasts. She has palpable cystic
lumps of about 1 cm in
diameter in both the upper outer quadrants of the right and left breasts. She
exhibits indentation of her
shoulders from bra straps. Her shoulders are rotated downwards and forwards.
DIAGNOSIS
Extreme macromastia, mastodynia, and fibrocystic disease of the right and left
breasts.3
COMMENTS
1.
I have discussed with the patient the treatment of this condition with bilateral
reduction mammaplasty.
2.
The patient is considering the ramifications of this procedure with its attendant
sequelae and possible
complications. No decisions for surgery have been made.
3.
Please review the accompanying photographs which illustrate patient�s condition.
4.
The patient would appreciate a letter stating that bilateral reduction mammaplasty
would be covered
under her group health insurance program.
Sincerely,
1667 characters
1 Alternative: EE.
3 Remove the dictated numeral 1
since no other numbers are given.

HISTORY1
The patient is a 75-year-old white male being evaluated because of infection
involving the left leg. The
patient relates a history of an insect bite approximately 6 days ago to the left
lower extremity. The patient
subsequently sought evaluation in the emergency room and was treated and
discharged home. The patient
returned because of increasing symptoms, shaking chills, and fever. There is no
history of previous
allergy to insect bites. There is no history of allergies to any antibiotics.2 The
patient denies any past
history of a cardiac murmur.
MEDICATIONS3
Present treatment includes piperacillin and Flagyl intravenously.
LABORATORY
Creatinine 1.1 mg%. BUN 10. White blood count 8100 with 2 stabs and 63 segs.
Urinalysis:4
0-2 WBC/hpf.5
GENERAL: On examination the patient is an alert male in no acute distress.
HEENT: The sclerae are clear. Conjunctivae are clear.
NECK: Neck is supple. There is no adenopathy.
HEART: Regular rhythm without murmur.
LUNGS: Clear to auscultation.
ABDOMEN: Soft, nontender.
EXTREMITIES:7 Examination of the left lower extremity reveals erythema, warmth,
and swelling with
tenderness to palpation over the foot to the level of the mid calf. The pulses are
full and equal bilaterally.
There is no crepitus. There is no fluctuancy.8 There is no visible drainage.
IMPRESSION AND RECOMMENDATIONS

Cellulitis of the left leg in a 75-year-old male, secondary to insect bite. The
most likely pathogens are
streptococci and staphylococci. Will switch antibiotics to nafcillin to cover for
above organisms. Will also
obtain ASO titer. Elevation and rest.
1647 characters

2 The dictator mispoke, saying �no history of antibiotics to any allergies.� Edit
appropriately.
4 The combined form urinalysis
should be used rather than the dictated �urine analysis.�
5 The dictator says �WBC per high-power field.� Since �WBC� is abbreviated, �high-
power field� may be
abbreviated as well and a virgule (/) used to separate the abbreviations.
8 The dictated �fluctuance� is not a legitimate word; edit to fluctuancy.

Patient is a 49-year-old, right-hand-dominant Hispanic female who is now

approximately 6 months status
post a flame burn to her right hand. Patient initially underwent debridement and
split-thickness skin
grafting. Patient had an open wound of the right thumb for which the patient
underwent a groin flap
coverage to this area. Patient subsequently underwent a division of this flap.
Patient went on to a partial
loss of the flap, which resulted in exposure of a portion of the proximal phalanx
of the thumb. Patient
underwent several debridements and attempted reclosures with continued exposure.
Patient is now
brought back to the operating room for final trimming of the proximal phalanx to
allow soft tissue
closure.
745 characters

OFFICE NOTE (0:30)
The patient is an 85-year-old Portuguese woman with a history of severe bullous

pemphigoid, with
worsening of lesions. Because of failure to respond to steroid therapy both
topically and orally, I1 had
treated the patient with methotrexate.
She had contracture deformities of arms and legs noted. The skin showed a few raw
and many small and
large crusted lesions up to 10 cm in diameter throughout the body including some
hemorrhagic lesions on
the palate.
DIAGNOSES
1. Severe bullous pemphigoid.

2. Contracture deformities of arms and legs.
557 characters
1 Insert the pronoun I as the subject to complete the sentence.

ADMITTING1 DIAGNOSIS
Maxillofacial skeletal malformation consisting of a maxillary hypoplasia and
mandibular prognathism.
Maxillofacial skeletal malformations consisting of a maxillary hypoplasia and
mandibular prognathism.
OPERATIONS
The patient had a LeFort I maxillary osteotomy and bilateral mandibular sagittal
split osteotomies.
BRIEF HISTORY
The patient is an 18-year-old female who3 has had a developmental skeletal
discrepancy between the
maxillofacial bones.4 Her past medical history was positive only for a surgery
about a year ago for
correction of scoliosis with rods placed in her back. She has had no other
hospitalizations or surgeries.
There were no allergies, and she is on no medications at this time.
LABORATORY FINDINGS
WBC of 6300.5 Hemoglobin of 12.7, hematocrit of 36.6. UA within normal limits. Pro
time6 and PTT
within normal limits. Chest x-ray was negative with the exception of the
Harrington rods next to the
dorsal spine.
HOSPITAL COURSE
The patient�s course in the hospital was uneventful. She tolerated the surgical
procedures very well. Her
postoperative course was benign.
DISCHARGE INSTRUCTIONS
The patient is discharged today. She is to be seen in my office. She is to be on a
full-liquid diet. She is to
avoid any strenuous physical activity. She is to be on penicillin V potassium (pen
VK)7 500 mg q.i.d. for
1 week. She is given a prescription for Tylenol with Codeine 12 mg/5 mL,8 to be
taken 10-15 mL9 q.4 h.
p.r.n. pain. She is given instructions to maintain good oral hygiene with half
peroxide and half water
mouth rinses q.i.d., as well as brushing as well as using other mouth rinses as
she desires. She is also
given instructions as to how to cut the interdental wires in case of respiratory
emergency, and instructions
were given to have her carry a small pair of needle-nose wire cutters.
PROGNOSIS
The patient�s prognosis is very good for complete recovery.
1915 characters

Expand brief forms in headings.
When same is dictated for a diagnosis, type the diagnosis in full.
Insert who to complete the sentence. Alternative: female. She has . . .
Omit the dictated paragraph command and continue the text under Brief History.
Alternative: 6.3 thousand.
Alternative: Prothrombin time is preferred , although pro time, when dictated, is
acceptable in laboratory data.
The dictated slang form �pen VK� is expanded to penicillin V potassium.
The dictated �cc� is on the dangerous abbreviations list and should be replaced
with the equivalent mL (milliliter).
The dictated �cc� is on the dangerous abbreviations list and should be replaced
with the equivalent mL (milliliter).

PRINCIPAL DIAGNOSIS
Metastatic malignant fibrous histiocytoma of the left forearm.
PROCEDURES
Local resection of the lesion of the left forearm with intraoperative radiation
therapy and with rotation
flap.
DISCHARGE MEDICATIONS
None.

Patient is a 70-year-old white female with a history of malignant fibrous
histiocytoma of the left wrist,
who has an apparent metastatic disease in the left antecubital space confirmed by
biopsy.

The left wrist tumor has been excised twice. The second time was a wide local
excision with abdominal
pedicled graft.
HOSPITAL COURSE
Patient was taken to the OR for a wide excision of the tumor, intraoperative
radiation, and a
fasciocutaneous flap. Postoperatively she did well with no complications and was
scheduled to return to
clinic in 1 week.
840 characters

CHIEF COMPLAINT
Cleft lip-palate1 deformity.

Patient is a 4-month-old male with a unilateral cleft lip-palate for palatoplasty.
For detailed history and
physical examination, see dictation.
HOSPITAL COURSE
Patient was admitted to the craniofacial surgery service. His preoperative
evaluation was completed. He
was taken to the operating room where under general anesthesia he underwent a
unilateral cheiloplasty.
Postoperatively he resumed his usual feedings. Intravenous fluids were
discontinued. Suture line
remained clear. Edema was moderate. He was discharged with an intact lip repair on
the day after surgery
for followup in the office at 5 days for removal of sutures.
722 characters
1 Alternative: Cleft lip and palate.

GASTROINTESTINAL DICTATION #1
OFFICE NOTE (2:00)
He has had lower abdominal cramps for the last 6 or 7 months. He does note some
consistent relief with
the passage of bowel movement or gas. His weight has remained stable, and his
bowel habits have
undergone no recent changes. Although he generally describes always being under
stress, he admits that
he has much more difficulty handling the stress now than he used to. In the recent
past he had dyspepsia
with stress and was treated with Tagamet. Around this time he noticed some sexual
impotence that has
greatly increased the stress in his life. He is off Tagamet and taking
intermittent antacids with some
improvement in his sexual function.
His physical examination was unremarkable except for some left lower quadrant mild
tenderness. His
stool is Hemoccult-negative.
He underwent a prior sigmoidoscopy which apparently was unremarkable, and I have

reviewed his
barium enema. This reveals multiple diverticula throughout his left colon.
The symptoms clearly are suggestive of irritable bowel syndrome, mainly the lower
abdominal cramps
that are relieved with the passage of bowel movement or gas, and seem to be
related to the increased
stress that he has had over the last several months. With his normal sigmoidoscopy
and his barium enema
revealing no significant abnormalities other than the multiple diverticula, no
other workup would be
needed at this time. I discussed with him what we know about irritable bowel
syndrome, diverticulosis,
and the beneficial effects of high fiber or bran. To this end we recommended that
he be started on bran
therapy to increase the frequency and bulk of his stool. In view of his general
good health and the fact that
these abdominal pains have not interfered with his daily life, I expect him to do
well.
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OFFICE NOTE (1:30)
SUBJECTIVE
Patient is a 13-year-old white female seen by myself for an upper respiratory
infection. Patient was started
on erythromycin, and a Maxair metered-dose inhaler was added to her previous
medication. The patient is
brought in by her mother today stating that she had vomiting yesterday.1 She
vomited after every feed;
however, today she has been able to eat an English muffin without any further
vomiting. She denies
abdominal pain at this time. Patient did have a crampy abdominal pain yesterday
during the episodes of
vomiting. She did not notice any hematemesis. There was no diarrhea. Patient
continues with cough and
URI2 symptoms.
OBJECTIVE
Patient�s temperature is 98.3. She is very well-appearing. No acute distress.
HEENT without change from
last visit. Lungs clear to auscultation bilaterally. Heart: Regular rate and
rhythm. Abdomen: Hypoactive
bowel sounds. No hepatosplenomegaly. Nontender. No rebound or guarding. No
distention.
ASSESSMENT
Vomiting, probably gastroenteritis. Upper respiratory infection. Rule out
pneumonia.
PLAN
Chest x-ray, CBC with differential,3 and UA4 are ordered today. Abdominal x-ray
flat and upright is
ordered today. Patient is advised to drink Gatorade and to eat toast, rice,
bananas, and apples, and advance
diet as tolerated, and to follow up on the x-rays and laboratory work that is
ordered today.
1367 characters
1 On the job you would change yesterday or today to a date.

2 Alternative: upper respiratory infection (URI). In an office note, abbreviations
are usually acceptable.
3 Expand unacceptable brief form, �diff� (differential).
4 Alternative: urinalysis (UA). In an office note, abbreviations such as UA are
usually acceptable.
ADMITTING DIAGNOSIS
Pancreatitis.
Pancreatitis.
OPERATIONS
None.
COMPLICATIONS
None.
BRIEF HISTORY AND PHYSICAL

This patient is a 25-year-old male who has had a history of recurrent bouts of
abdominal pains,
presumably caused by pancreatitis, since an auto accident with severe abdominal
trauma, liver laceration,
and pancreatic injury. The patient had been in the emergency room twice by the
time of admission and
had gotten IV fluids and a pain shot, but the pain would not abate. Patient was
admitted for treatment of
his acute symptoms, and he had a white blood count of 20,300 with a left shift and
a temperature of over
103.
LABORATORY AND COURSE IN THE HOSPITAL
The patient was treated with pain shots. He was started on intravenous Tagamet.
Symptoms began
responding quickly. The fever came down with rectal Tylenol. Blood chemistry panel
shows protein
slightly below normal, cholesterol low at 91, sodium 134. The rest of the panel is
normal. Amylase was
checked twice, and both of the levels were normal, but I do not believe one was
obtained on admission
when patient�s symptoms were most acute. A followup white blood count showed the
white count had
dropped to 11,500, hemoglobin 12.1 g. Upper GI series was a limited study because
of equipment
difficulties. Enlargement of the pancreas was felt to be present, and no ulcers
were noted. Patient is
comfortable this morning. He has been eating normally. He did spike a temperature
yesterday2 to 100.8
but is afebrile now. Patient is ambulatory and essentially free of pain. He will
be discharged without
medication but was asked to refrain from alcohol and fatty foods and to report
further symptoms should
they occur. Prognosis is good.
1734 characters
1 If the dictator says �same� for the discharge diagnosis, copy the diagnosis in
full from the admitting diagnosis.

HISTORY
Patient is a 15-year-old white female, status post traumatic brain damage
secondary to head injury causing
severe mental retardation and cerebral palsy. She presents because of onset of
abdominal bloating and
leakage around her feeding gastrostomy tube and for evaluation of an abdominal
ileus. For further history
and physical information, please see the history and physical dictation.
HOSPITAL COURSE
Patient was admitted where she was put on gastrostomy tube drainage and was kept
n.p.o. She was given
strictly IV fluids. Because of the suspicion of a possible left mid and lower lobe
pneumonia, she was also
started on ampicillin. Nasogastric (NG)1 suction was also performed for the first
24 hours. Patient seemed
to respond to the above therapy, showing no evidence of rebound or guarding in the
abdomen. Her chest
remained clear and she remained afebrile. After 3-4 days of remaining n.p.o. and
having drainage from
the feeding gastrostomy, the tube was clamped and she was begun on full liquid
diet. This she tolerated
well without any problems. Her diet was gradually progressed with no problem.
Because of her good progress and no sign of recurrent ileus, it was felt that she
could be returned back for
further care.
IMPRESSION
Small-bowel ileus, probably secondary to viral gastroenteritis.
PLAN
1.
She is to resume her previous orders except for the following: She should continue
ampicillin
250 mg q.i.d. for another 5 days.
2.
Change from Ensure to Compleat 1 can 4 times a day with her meals.
3.
Will follow her up.
1553 characters
abbreviation in parentheses.
An elderly lady with multi-infarct dementia who was admitted following a fall at
home in which she
injured her knee and back. In the process of the immobility incurred following the
fall plus taking
analgesics, she became quite constipated, then began having diarrhea. She was
treated with over-thecounter
measures for diarrhea which seemed to improve and then recur,1 but she became
increasingly
weak. She was brought to the office on the day of admission by her elderly husband
and was found to
have a very large fecal impaction with liquid stool oozing around the impaction.
She and her elderly
husband were unable to manage this situation. In addition, she was becoming
increasingly immobile,
distended, and required colonic evaluation as well. Also, the right knee was
acutely effusive and tender,
and she was unable to stand, and therefore hospitalization was advised for
disimpaction of the rectum,
evaluation of the colon, and evaluation of the knee, as well as general care,
which was unable to be
rendered at home.
History and physical is as dictated.
The patient was seen in regard2 to the knee. Conservative treatment was advised.
The disimpaction was
accomplished by the nursing staff, and there was no evidence of obstruction on the
plain film of the
abdomen. Degenerative changes noted on x-rays of the knee. Electrocardiogram
revealed left bundle
branch block. Routine screening lab otherwise stable.
Patient was discharged the following day in poor condition with a guarded
prognosis, to continue her
regular cardiac medications and a rigorous bowel program. She will be followed in
the office and a
colonic workup performed as an outpatient.
FINAL DIAGNOSIS
1. Acute fecal impaction.

2. Acute traumatic arthritis of the knee.
3. Multi-infarct dementia.
4. Cardiomyopathy with chronic congestive heart failure.
1846 characters
1 The dictated �reoccur� is edited to recur, the standard term.

2 Edit �regards the knee� to in regard to the knee for proper usage.

A 65-year-old woman who was found at home 1 day prior to operation in a very
confused state. Workup
revealed severe diabetic ketoacidosis. Over the ensuing 36 hours, she developed a
septic-appearing
picture, requiring pressor support and intubation. Prior to intubation she
complained of right upper
quadrant pain, and an ultrasound revealed an emphysematous gallbladder with air in
the biliary tree. No
biliary ductal dilatation was noted, and no stones were noted. Due to the
patient�s continuing downhill
course, she was taken to the operating room for emergent biliary drainage.
606 characters

This 34-year-old Caucasian male was admitted via emergency room with a 3-day
history of significant
epigastric pain. The dictated history and physical is not on the chart.
Patient�s examination on admission demonstrated some significant epigastric

tenderness but without
peritoneal signs. He was afebrile. His white count was approximately 25,000 on
admission.
He was admitted and taken to the operating room, and upper gastrointestinal
endoscopy was performed.
Patient was found to have distal esophagitis and gastritis and was thought to have
a large bulbar ulcer. An
upper gastrointestinal series showed only a small ulcer. Patient�s abdomen
remained tender, and his white
count had advanced to 33,000. He did have a low-grade temperature,1 and a
gallbladder ultrasound
demonstrated cholelithiasis and probably acute cholecystitis. The patient was then
taken to the operating
room, and a cholecystectomy was performed under general anesthesia. The patient
was found to have
gangrenous cholecystitis.
Patient�s postoperative course was basically unremarkable. He was passing a trace

amount of bile around
his sump. However, he was discharged afebrile, tolerating a regular diet. Drain
was removed. To be seen
in my office in a week. He is passing his water, moving his bowels, and so forth.
The skin staples will be
removed in the office. No evidence of wound infection.
1395 characters
1 Expand unacceptable brief forms such as �temp.� Experienced transcriptionists

might edit to fever.

ADMITTING DIAGNOSIS
Alcohol-related pancreatitis and alcohol addiction requiring detoxification.
FINAL DIAGNOSIS
1. Alcohol addiction and alcohol-induced pancreatitis.

2. Acute influenza with right middle lobe infiltrate.
REASON FOR THIS ADMISSION
Patient is a 36-year-old gentleman with a recent hospitalization for pancreatitis
and a past history of
addiction to alcohol and cocaine, having detoxed from methadone 2 months ago. He
was2 discharged 2-33
weeks ago and was alcohol-free for several weeks, but now, for the last 10 days,
he has been drinking
beer on a daily basis. He is now being readmitted for placement in a detox setting
because he is acutely
anxious and intoxicated.
The physical exam is within normal limits.
PERTINENT LABORATORY DATA

HIV is negative. Blood cultures x2 are negative. Admitting blood count is normal
with a hemoglobin of
13.9 and white count 5600. Alcohol level was 196 mg/dL.
HOSPITAL COURSE
The patient�s hospital course is as follows: The patient was admitted and had a
normal amylase
and lipase, in contrast to his marked elevation of amylase and lipase on his
previous alcohol-
related admissions. He was evaluated in the medical psychiatric unit for transfer
to a detox
facility; however, the patient became anxious to go home and refused further
admission. The
patient developed swollen glands and a very high temperature of 103 the day prior
to his
discharge. It was felt that he probably had influenza, as there was an epidemic of
influenza
going around at the time of his symptoms, and within 24 hours he was afebrile,
feeling much
better, and wanted to go home. He admitted that he was going home to drink more,
was very
hostile, and left the hospital against medical advice.
1758 characters
1 Numeral 1 is added since numeral 2 is dictated. It is customary to number the

diagnoses when there is more than
one.
2 Edit the dictated is to was for proper verb tense.
Alternative: 2 to 3 weeks.

The patient, a 10-year-old female child, was admitted to the emergency room with
chief complaint of
abdominal pain. The illness started about 10 or 11 hours prior to admission with
periumbilical pain
localizing over the right lower quadrant. This was associated with nausea and
increasing tenderness up to
the time of admission.
On admission, admitting laboratory examination showed elevated WBC and shift to

the left.
Shortly after admission the patient was taken to surgery. Appendectomy was carried
out.1 Postoperative
course was quite uneventful. She was discharged on the 2nd postoperative day to
return to the clinic for
followup.
FINAL DIAGNOSIS ON DISCHARGE

Acute appendicitis.
706 characters
1 Complete the phrase for this ESL dictator.

This is a 31-year-old married white female, gravida 3, para 1-0-1-1, who was
admitted through the
emergency room. She is a regular patient in our practice. She was having
persistent nausea and vomiting
in early pregnancy. She is 14 weeks pregnant. See the Present Illness and Physical
Examination for
further details.
Her signs and symptoms were more than just the average hyperemesis of pregnancy,
and she was in fact
beyond the 1st trimester, and she was seen in consultation, and a gallbladder
sonogram performed the
morning after admission revealed sludge in the gallbladder with normal liver
function tests.1 We
attempted to treat this patient with intravenous therapy and slow liquid feedings.
However, a surgical
consultation was obtained as well from2 the general surgical service, and because
the patient persisted in
these symptoms, a gastroscopy was performed which was totally normal. Because of
this, and because of
her persistent symptomatology, and after great and lengthy consultation with the
patient and her husband
and family, she elected to undergo a cholecystectomy under general anesthesia,
without any
complications. The patient did extremely well postoperatively, began having
regular food by the 3rd
postoperative day, and was discharged on the 4th postoperative day and also to be
followed for regular
prenatal care in our office on a regular basis.
FINAL DIAGNOSIS
Cholecystitis and cholelithiasis (sludge) at 14 weeks of pregnancy.
1481 characters
1 This long and complex sentence could be edited to shorter sentences.

2 The dictator stumbles, saying �with� and then changing it to �from.�

HISTORYPatient is a 78-year-old female with a long history of Crohn�s2 disease and

multiple abdominal procedures
for segmental small-bowel resections. She also has had two chronic nonhealing
fistulas for a number of
years and has been chronically malnourished while living alone. Over the past
several months she has had
progressive weight loss, fatigue, breathlessness on exertion, and general decline
in her overall status. She
was 3 admitted at this time for evaluation and possible hyperalimentation.
The remainder of the history and physical examination is4 as dictated in the
admission note.
HOSPITAL COURSE
On admission, chest x-ray was unremarkable. Electrocardiogram showed low voltage,
frequent premature
ventricular depolarizations, left axis deviation, and QT prolongation. Hemoglobin
on admission was 11.4,
serum sodium 129, albumin and total protein markedly reduced at 1.6 and 3.7,
respectively. Serum
cholesterol was 32.
The patient was seen in consultation by the surgery section, and an indwelling
superior vena cava catheter
was placed for hyperalimentation. The patient was begun on supplemental
hyperalimentation and
eventually had a permanent catheter placed. Her hospital course was complicated by
some difficulty with
fluid retention and dependent edema. She was eventually able to be discharged to a
local skilled nursing
facility with arrangements made for continued hyperalimentation as an outpatient.
Discharge medications included Lasix 80 mg daily, prednisone 15 mg every other

day. There were no
specific activity restrictions.
FINAL DIAGNOSIS
1. Crohn�s disease with chronic malnutrition.

2. Nonhealing abdominal fistulae.
3. Electrolyte imbalance.
1697 characters
1 Headings and paragraphs are added for consistency in format.

2 Alternative: Crohn disease. The use of the possessive form of eponyms is
acceptable when it is dictated or when it
is preferred by the employer or client.
3 Edit is to was for proper verb tense.
4 Edit are to is for proper subject-verb agreement (�remainder . . . is�).
Patient was admitted with a history of a severe anal prolapse and uterine
prolapse. Patient had become
quite symptomatic and was having excoriation of the perineum due to drainage from
the anal canal. She
was noted to have a very patulous anus with minimal sphincter tone; however,
because of the prolapse,
the patient was constantly having drainage on the perineum.
The significant past history included a myocardial infarction. Also had a history
of hypothyroidism,
urinary retention, and bladder dysfunction.
Following the patient�s admission to the hospital, she underwent surgery. The
surgery itself was
successful. Postoperatively, though, the patient had a considerable amount of
abdominal pain and
discomfort, necessitating a Foley catheter to be inserted. Several times the
catheter was removed, but the
patient was unable to void, requiring that the catheter be reinserted. The patient
was started on sitz baths,
stool softeners, and her diet was initially poorly taken, but then the patient�s
dietary intake improved.
After about the 5th day, she had some bowel activity, at first incontinent, but
then began to have more
control over her bowels. By the 7th postoperative day, the patient was doing well
enough that we thought
she could be discharged home.
FINAL DIAGNOSIS AT THE TIME OF DISCHARGE
1. Anal prolapse.
2. Hemorrhoids.
3. Hypotension.
4. Postoperative nausea.
5. Urinary retention.
6. Bladder dysfunction.
7. Arteriosclerotic heart disease (ASHD).2
8. Status post myocardial infarction (MI).3
9. Hypothyroidism.
10. Uterine prolapse.
SURGICAL PROCEDURE
Hemorrhoidectomy and anoplasty.
1619 characters
1 Number diagnoses when there are more than one.

2 Expand an abbreviation in the diagnosis and place the abbreviation itself within
parentheses.
parentheses.

A1 43-year-old Caucasian female with a history of right upper quadrant pain came
to the emergency room
with significant midabdominal pain radiating through to the back. A gallbladder
ultrasound and physical
examination were2 compatible with acute cholecystitis.
She was taken to the operating room, and an esophagogastroduodenoscopy and

cholecystectomy were
performed under anesthesia. The patient�s postoperative course was unremarkable.
Her activity was
increased. Her abdomen was soft and her diet was increased, and later on that day
she was discharged in
improved condition, tolerating a regular diet, walking around, doing all of the
human activities.
Medications included Tylox. She was to be seen in my office in a week.
752 characters
1 Alternative: This may be added to avoid starting the sentence with a numeral.
2 Edit was to were for proper subject-verb agreement (�ultrasound and . . .
examination . . . were�).

She has been followed the last several years with a syndrome suggesting possible
granulomatous colitis
with intermittent diarrhea but has also been sensitive to a number of drugs
producing diarrhea such as the
thiazide diuretics back in the early �60s.1 She has required treatment with these
drugs because of
idiopathic edema in spite of a very low-salt diet. She was currently on Carafate
as well as Pepcid for acid
peptic symptoms. During the past month she had had as many as 23 stools a day and
been started on
steroid therapy, which had almost totally controlled her diarrhea, but she became
increasingly thirsty,
having frequent urination, and blood sugar on the day of admission in the office
was 494.2
Her physical examination was unremarkable. She also had a history of psoriasis
which was under great
control with recent steroid therapy.
White blood count was 14,400 and hemoglobin 14.2. The elevated white blood count
was probably
related to steroid therapy. Sedimentation rate was 30. Chemistry profile showed a
slightly low sodium at
132 and a potassium of 3.3, which corrected to potassium of 3.9. Sodium was still
somewhat slightly low
at 132 at the time of discharge. Urinalysis3 was unremarkable. The remainder of
the chemistry profile was
unremarkable. Stool for ova and parasites and culture revealed no ova and
parasites seen on two
occasions and no enteric pathogens.
The patient was treated with a 1400-calorie, 2-g low-sodium diet. Blood sugar in
the hospital was
approximately 340 on the Accu-Chek meter. She was given 15 units of regular
insulin. Blood sugar
dropped to 119, and the other sugars that were done on the 12th were 110, 152, and
164. The last sugar
was 168. It was felt that her blood sugar came quickly under control with diabetic
diet and with
discontinuing of steroids. Interestingly, her diarrhea did not increase. She was
given several doses of
Micro-K to raise the potassium level. Her Pepcid was continued as well as
Carafate. She was seen in
consultation. In view of the negative studies for ova and parasites and the fact
that her diarrhea did not
return in the hospital, we felt4 that she could be followed in the office, and we
would see her in office in
approximately 1 week.
She was discharged on her regular medications: Carafate, Pepcid, but no steroids
and on a 1400-calorie,
2-g low-sodium diet.
FINAL DIAGNOSIS
1. Diabetes mellitus, out of control.

2. Colitis, nonspecific.
We will arrange during the next week for the patient to learn to check her own
blood sugars with an
Accu-Chek meter. She will be seen in my office in 1 week.
2601 characters

1 Use a preceding apostrophe in shortened numeric expressions relating to decades
of the century.
2 New paragraphs are added to divide sections of the report appropriately.
3 The combined form urinalysis should be used rather than the dictated urine
analysis.
4 The pronoun we is added to provide a subject for the verb felt.

This 76-year-old white female presented to my office complaining of angina with

effort, fatigue, malaise,
cold intolerance, all going on for about 3 weeks. At the onset of the symptom
complex, patient had some
dark stools and vomited some material that sounds like coffee-grounds-type1
substance. Patient�s
hemoglobin was found to be 5.8 with hematocrit of 20.2 and microcytic indices.
Patient was admitted for
a workup and transfusion.
Physical exam revealed a well-developed, well-nourished white female appearing

pale but in no acute
distress. The skin was pallid. The chest was clear to percussion and auscultation.
Cardiovascular exam
revealed pacemaker implant, right upper chest wall. The rhythm was regular at 75,
without murmur,
gallop, rub, or click. Pedal pulses 2+. Femoral pulses 1+. The abdomen was soft,
nontender, without
organomegaly, mass, or bruit. The pelvic and rectal exams were unremarkable except
initially the stool
was dark brown and Hemoccult-positive. There was no cyanosis, clubbing, or rubor
to the extremities.
There was 1+ pedal edema.
Subsequently 3 stools for occult blood were negative. B12

2 and folic acid levels were within normal limits
(WNL).3 The serum iron was low at 13 with an elevated serum iron-binding capacity.
Chest
x-ray was unremarkable. Upper GI series with4 small-bowel follow-through revealed
a large sliding hiatal
hernia, otherwise unremarkable. Barium enema was unremarkable except for moderate
hypertrophic
sigmoid diverticulosis. Electrocardiogram revealed a normally functioning atrial
pacemaker, otherwise
unremarkable.
COURSE IN HOSPITAL
Initially saline was infused to restore plasma volume, and then the patient was
transfused with 4 units of
packed red blood cells. After that she was totally asymptomatic and remained so
throughout her workup.
An upper GI endoscopy was unremarkable except for the large hiatal hernia.
As noted above, patient�s stools became Hemoccult-negative. Her hematocrit and

hemoglobin remained
stable post transfusion. I placed the patient on Zantac, for I do believe she had
a UGI bleed, probably
secondary to her nonsteroidal anti-inflammatory agent therapy.
At the time of discharge, patient is asymptomatic. Her abdomen is soft, nontender.

Bowel sounds are
normal. She is up and about, feeling quite well and quite ready to go home.
FINAL DIAGNOSES
1. Massive gastrointestinal bleed, exact source undetermined.

2. Essential hypertension.
3. Primary hypothyroidism.
4. Arteriosclerotic cardiovascular disease (ASCVD)�congestive heart failure
(CHF).5
PLAN
Patient is discharged home on her usual medications plus Zantac 150 mg b.i.d. for6
3 weeks, then nightly7
for8 3 months. I have instructed her to avoid gastric irritants and stimulants,
particularly nonsteroidal antiinflammatory
agents, aspirin, etc. I will see the patient back in my office in 2 weeks in
followup.
2875 characters
1 Coffee-grounds is plural.
Alternative: B12.
3 Expand an abbreviation on first use in the body of the report and place the
4 Edit �UGI/� to �Upper GI (or gastrointestinal) series with� so that it is clear
which x-ray study was done.
parentheses.
6 When the word times is dictated and can be translated as for, use for rather
than times or the symbol x.
should be replaced with nightly or at
bedtime.
8 When the word times is dictated and can be translated as for, use for rather
than times or the symbol x.

ADMISSION DIAGNOSIS
Gastrointestinal (GI) bleed.1
FINAL DIAGNOSIS
1. Gastrointestinal (GI)2 bleed secondary to peptic ulcer disease.

2. Systemic arterial hypertension.
3. Diabetes mellitus.
4. Past history of unstable angina. Patient is stable at this time.
BRIEF HISTORY
This is a 57-year-old female who was seen in the office on the day of admission
with complaint of having
dizziness and difficulty maintaining her balance. Patient complained of a
spinning-type sensation. She
also complained of light-headedness. There was no nausea or vomiting, but she had
had some black stool.
She indicated that her stools at the time of examination were beginning to clear
up.
Patient had had no chest pain or shortness of breath, no paroxysmal noctural

dyspnea (PND),3 pedal
edema, or orthopnea.
She was referred to the emergency room where she was evaluated and was found to
have a hemoglobin of
6 and a hematocrit of 20.3. She was subsequently admitted for appropriate
evaluation and therapy.
PERTINENT PHYSICAL FINDINGS

This patient presented as a well-developed, well-nourished female, moderately
obese, in no acute distress.
Blood pressure was 147/96 with pulse of 110 and respiratory rate of 20. In the
office it had been 200/80.
HEENT within normal limits with the exception of paleness of the conjunctivae.
Neck was supple
without adenopathy or thyromegaly. Lungs were clear. Heart: Regular rhythm without
gallops. Patient
was noted to be tachycardiac. Abdomen was soft and nontender. Bowel sounds
normoactive. Pelvic
deferred. Rectal: Melenic4 heme-positive stools. Extremities within normal limits.
Neurological: Normal.
PERTINENT LABORATORY STUDIES

An admission glucose was 239, creatinine 1.8, BUN 54, sodium 139, potassium 4.8,
chloride 107, carbon
dioxide 23. Final glucose 118, BUN 27, creatinine 1.5, sodium 142, potassium 4.6,
and chloride 109.
Digoxin level 0.4.5 CBC on admission as indicated above with hemoglobin 6.4,
hematocrit 20.3.6
7 8910
Followup CBC on February 15:WBC 9600, hemoglobin 11.7, hematocrit 35.6. Urinalysis
showed 25
WBC/hpf, otherwise unremarkable. Number of units of blood transfused: 4. Remainder
of laboratory
studies: CPK 188, cholesterol 253, triglycerides 234. Iron was 204, albumin 2.6,
total protein 5.0. Chest
x-ray was negative. EKG: Normal sinus rhythm and was essentially within normal
limits.
HOSPITAL COURSE
This patient was admitted to the regular floor. She was on IV fluids, 5% dextrose
in half-normal saline11
125 mL/h.12

In addition patient was started on IV Zantac 50 mg q.8 hours13 which she tolerated
quite well. She was
immediately transfused 2 units of packed red blood cells, and consultation was
requested.
This patient underwent gastroscopy which showed pyloric channel ulcer. She did
indeed respond to the
IV Zantac. She did not undergo colonoscopy.
With reference to her diabetes mellitus, she was continued on Novolin 70/30
fifty14 units subcu q.a.m.15
Procardia XL 30 mg p.o. daily was continued for treatment of her hypertension as
well as her Minipress 2
mg p.o. t.i.d. and Nitro-Bid 2.5 mg p.o. b.i.d. She had no chest discomfort or
chest pain during
hospitalization, and her blood pressure remained stable. Her CBC stabilized with
the use of Zantac, and
her stools became brown during hospitalization.
Her glucose was noted to be somewhat low during hospitalization in the afternoon
and evening, and
therefore her insulin in the evening was held. This was felt to be to due to a
strictly controlled diet which
patient does not receive at home.
Her condition on discharge is much improved and stable.
Zantac 150 mg p.o. b.i.d.; Nitro-Bid 2.5 mg p.o. b.i.d.; Minipress 2 mg p.o.
t.i.d.; Novolin 70/30 fifty16
units subcu in the a.m., will hold the p.m. 10 units at this time. Procardia XL 60
mg a day, which was
increased after patient was hospitalized.
DIET
Bland, 1500-calorie ADA.17
ACTIVITY
Activity as tolerated.
PLANS FOR FOLLOW-UP

I will see the patient in the office in 1 week, and at that time a blood count
will be checked as well as
stools for occult blood.
4065 characters
1 Expand an abbreviation used in the diagnosis and place the abbreviation within
parentheses.
2 Expand an abbreviation used in the diagnosis and place the abbreviation within
parentheses.
3 Expand an abbreviation used in the body of the report and place the abbreviation
within parentheses.
4 Physicians often dictate melanotic when they really mean melenic from melena
(tarry black color of stools).
Melanotic pertains to melanin.
6 The dictator says �H&H� (slang). It is incorrect to present hemoglobin and
hematocrit this way. Alternative:
hemoglobin and hematocrit 6.4 and 20.3.
7 Edit the dictated �2/15� to month and day.

8 Alternative: 9.6 thousand.
9 The dictator says �H&H 11.7/35.6.� It is incorrect to present hemoglobin and
hematocrit this way. Edit
appropriately. Alternative: hemoglobin and hematocrit 11.7 and 35.6.
10 Do not paragraph before urinalysis, even though the dictator gives that
instruction, because the information is a
continuation of the laboratory data.
11 To avoid errors or confusion, the dictated �D5 and a half� (a mixture of
dextrose and saline) should be written D5
in half-normal saline.
12 The dictated �cc� is on the list of dangerous abbreviations and should be
replaced with its SI equivalent mL
(milliliters).
14 To avoid having two sets of numbers together, one numeral may be written out
for clarity. Alternative: comma
between numbers.
16 To avoid having two sets of numbers together, one numeral may be written out
for clarity. Alternative: comma
between numbers.
17 Although it stands for American Diabetes Association, ADA is not expanded when
used as the name of a diet.

FINAL DIAGNOSIS
Early acute appendicitis.
OPERATION
Appendectomy.
HOSPITAL COURSE
This is an 18-year-old white male who was in his usual state of good health until
approximately 3-4 days1
prior to admission, when he developed vague back pain eventually radiating around
to the anterior
abdomen and became generalized. In the emergency room the evening prior to
admission, he had
generalized abdominal pain but with a white count of 18,000, but no fever. On the
day of admission, he
still had no fever but pain became much more localized to the right lower
quadrant. He became anorectic,
associated with nausea and emesis x1. He denied any history of diarrhea, urinary
frequency, or dysuria.
There was no history of any inflammatory bowel disease, urinary tract infection,
or stones.2
Physical examination revealed a tender right costovertebral angle (CVA),3

radiating4 to the anterior
abdomen. Bowel sounds were present, but there was moderate tenderness in the right
lower quadrant over
McBurney�s5 point. Rectal examination showed mild tenderness in the right side.
The chest was clear
with occasional expiratory wheeze.
The patient has been on Keftabs for bronchitis for a long-standing history of
childhood asthma. Because
of the history of antibiotic usage, there was some confusion as to whether or not
this might in fact be a
masked appendicitis, and therefore, because of the persistent problem, it was
recommended to undergo
appendectomy, at which time early inflammatory changes of the appendix were noted.
Postoperatively the patient did well, having the usual postoperative incisional
pain. His back pain did
significantly improve, and he remained afebrile. He was maintained on inhaler for
his asthma. By the 2nd
postoperative day he was taking oral intake well and passing flatus, and his diet
was advanced. His
intravenous fluids were discontinued, and he was begun on p.o. antibiotics of
Keflex 500 mg
q.6 h. Patient remained afebrile, had a normal bowel movement, but had some nausea
on the 3rd
postoperative day. His diet was advanced again, and at this time he was eating
well with no nausea or
vomiting. He only complains of mild incisional tenderness. He was discharged home
and given a
prescription for Vicodin tablets #15 with 1 refill. He will continue the Keftabs
at home. An office
appointment will be made for 7-10 days,6 and diet and activity instructions were
given as well.
2424 characters

1 Alternative: 3 to 4 days.
2 New paragraphs are added to separate sections of the report appropriately.
3 Expand an abbreviation on its first use in the body of a report and place the
4 The CVA is not radiating; pain or tenderness is implied.
5 Alternative: McBurney point. The use of the possessive form of eponyms is
acceptable when it is dictated or when
it is preferred by the employer or client.

Patient is a male who was in a high-speed motor vehicle accident, sustaining a

grade 4 or 5 liver
laceration. He underwent exploratory laparotomy with packing of the liver. He also
had a grade 1 spleen
laceration, and his spleen was packed. He has been in the intensive care unit. He
is warm. His acid-base
status is normal. He has been fully resuscitated with packed red blood cells,
platelets, fresh frozen plasma
(FFP),1 and cryoprecipitate. We therefore will return to the operating room for
removal of packs.
537 characters
1 Expand an abbreviation on its first use in the body of a report and place the

This 58-year-old female gives a greater than a 48-hour history of vague abdominal
pain with anorexia that
has localized in the last several hours into the right lower quadrant. She has
peritonitis by physical exam.
Her fever was 101. The CT scan revealed a phlegmon surrounding a small hollow
viscus consistent with
acute appendicitis.
357 characters

The patient is approximately a week and a half status post live-donor liver
transplant, who did very well
initially, and on postop day number 5 developed bile in one of his Jackson-Pratt
drains. A HIDA scan
revealed that this drainage was well controlled by the Jackson-Pratt drain and
appeared to be coming from
the cut surface of the liver, although an anastomotic source could not be ruled
out. Of note, his live-donor
transplant consisted of a Roux-en-Y hepaticojejunostomy with two separate bile
duct anastomoses. We
elected to observe him, as he was asymptomatic and had good liver function
studies, to see if this would
seal off on its own. After approximately 3 days of observation, however, it was
clear that there was no
diminution in the amount of bile coming through the drain, and we therefore
elected to explore him in an
attempt to repair the bile leak.
892 characters

GENITOURINARY DICTATION #1
Patient has a symptomatic recurrent right groin hernia. He and his family
understand all the risks and
benefits of the repair including but not limited to atrophy or potential loss of
the testicle, numbness in the
area, bleeding, infection, and recurrence againi of the hernia. They accept these
risks and agree to
proceed.
347 characters
i The dictator says �re-recurrence.�

Patient is a 65-year-old white male status post radical prostatectomy for

carcinoma of the prostate, who
during that same year underwent implantation of an inflatable penile prosthesis
for organic impotence
secondary to the radical prostatectomy. The prosthesis has been malfunctioning for
a number of years and
is causing the patient pain in the right scrotum, and on exam the pump device
seems to have eroded into
the right testicle, as they are indistinguishable from one another.1 Patient now
presents for removal of the
malfunctioning penile prosthesis and insertion of a new inflatable penile
prosthesis.
634 characters
Omit redundant on exam.

A 98-year-old white female with history of weakness. She was a resident of a

retirement center and had
had difficulty ambulating; was unable to reach the bathroom except with a great
deal of assistance.
Physical examination showed a chronic injury to the right side of the face with
blindness in the right eye.
Blood pressure was normal. Lungs were clear to auscultation and percussion. She
was somewhat pale.
Electrocardiogram showed no acute problem. Pyuria was present on the urinalysis.1

Her white count was
21,000, potassium of 3.3, 4+ bacteria in the urine.2 Chest x-ray showed no
evidence of an acute infiltrate.
The patient had been digitalized and was taking a diuretic, which probably
accounts for her hypokalemia.
She had a low-grade fever at times during her hospital stay but after a few days
began to regain some
strength. She was quite alert considering her advanced years. Initial therapy
consisted of continued
Lanoxin and Lasix 20 mg 5 days a week. Salt restriction was afforded her, and she
was begun on Bactrim
for the urinary tract infection (UTI).3 Potassium supplements were given in the
form of KCl t.i.d.
Multivitamin was also afforded her. She was allowed to use her own eyedrops. Had
difficulty with
urinary control, and Ditropan t.i.d. was begun. She was discharged the next day,
and the Ditropan is
continued. I do not know at this time if it will be helpful. Her chest x-ray
showed pulmonary fibrosis and
chronic bronchitis. First degree AV block was present on her electrocardiogram on
the 17th4 with some
nonspecific changes, but no acute problems were in evidence. Her white count,
which was 21,100 on the
17th, became 9300 on the 19th. Digitalis5 level was 1.2. Urinalysis improved after
Bactrim. Her strength,
as indicated above, improved in a few days, and she was discharged to continue on
Lanoxin, potassium
supplement, salt restriction, and diuretics as an outpatient. Her potassium will
be monitored as an
outpatient.
FINAL DIAGNOSIS6
1. Urinary tract infection.

2. Arteriosclerotic heart disease with chronic congestive heart failure, well
controlled by Lanoxin,
diuretics, and salt restriction.
3. Hypokalemia, improved with potassium supplement.
Prognosis is guarded due to her advanced years.
2261 characters
1 The combined form urinalysis is preferred to urine analysis.
Alternative. New sentence: There was 4+ bacteria in the urine.

parentheses.
4 Full dates should be transcribed, if known.
5 The dictated slang term �dig� should be expanded to digoxin, digitoxin, or
digitalis. If you cannot determine from
the dictator or the chart which drug is intended, you may transcribe digitalis or
type the brief form dictated.
6 Numbers are added to the diagnosis when there is more than one.

HISTORY
This 31-year-old female was admitted through the emergency room with acute right
ureteral colic. The
patient had a previous history of ureteral colic for 3 months off and on, much of
this not really ureteral
colic but more right abdominal pains. She had urinary tract infection symptoms and
microhematuria.
Patient presented to the ER about a month ago, and the impression at that time was
that there was a
possible ureteral stone. The ER doctor scheduled patient for an1 intravenous
pyelogram (IVP)2 in the
morning, but the patient apparently did not return for this. The patient now
returned to the emergency
room with right ureteral colic and microhematuria. She is also nauseated and
having some vomiting.
Patient underwent an IVP which shows an 8 x 5 mm calcification in the right

hemipelvis, in
approximately the tract of the right ureter. The right kidney is obstructed3 with
nephrogram effect only on
the 3 p.m. film with no visualization of the ureter thus far. The left kidney and
ureter seem normal
without obstruction. The patient is being admitted for further followup and
treatment.

Cesarean section x1. No previous surgery or medical history otherwise.
ALLERGIES
Compazine.
MEDICATIONS
None.
SOCIAL HISTORY
Married. One child.
GENERAL:4 This is a well-nourished female in acute right ureteral colic with
nausea.
HEENT: Pupils are equal, round, and react to light. Ears, nose and throat clear.
NECK: Supple.
LUNGS: Clear to percussion and auscultation (P&A).5
HEART: Regular rhythm. No murmur.
ABDOMEN: Soft. Tender right lower quadrant, right costovertebral angle (CVA)6
area. No rebound, no
guarding.
EXTREMITIES: Without cyanosis, clubbing, or edema.
NEUROLOGICAL: Neurologically oriented x3 with no gross deficit.
PELVIC AND RECTAL: Pelvic and rectal exam not performed at present.

IMPRESSION
Right lower ureteral colic with probable right lower ureteral stone with
obstruction.
RECOMMENDATION
Admission for analgesia, hydration, and further observation with followup x-ray
films and possible
subsequent treatment.
2100 characters
1 Edit dictated a to the appropriate article an before a vowel sound.

2 Expand an abbreviation on first use in a report and place the abbreviation
itself within parentheses.
3 Edit obstructive to obstructed for accuracy. The right kidney is not what is
blocking something.

The patient was admitted to the hospital for elective transurethral resection of a
bladder tumor found on
cytoscopy in the office. The patient went to the operating room where
transurethral resection was
performed, including the left ureteral orifice. The pathological diagnosis was
transitional cell carcinoma
of the bladder, noninvasive, grade 2. The patient was voiding satisfactorily and
was discharged for office
followup in approximately 10 days, discharge medications consisting of Pyridium
200 mg 1 t.i.d. p.r.n.
and Septra double-strength1 1 b.i.d. The patient was instructed that, because of
the resection of the left
ureteral orifice, intravenous pyelography will be necessary in approximately 6
weeks.
FINAL DIAGNOSIS
Transitional cell carcinoma of the bladder.
794 characters
1 The drug is properly known as Septra DS (double-strength). It�s unusual for a

doctor to dictate �double-strength�
rather than �DS.�

A 73-year-old Caucasian male with a symptomatic right inguinal hernia. There is

some nocturia but no
overt prostatism, and he has had an1 increasing irregularity manifested by
constant constipation over the
last several years.
He was admitted and underwent a right inguinal hernia repair and an attempt at
colonoscopy. I could not
advance2 past the splenic flexure, and he3 had such a poor prep that I could not
decisively say4 whether
there was any pathology or not. What I saw was negative. Will get a barium enema,
most likely as an
outpatient, after his hernia is healed. The patient underwent the hernia repair
without difficulty and was
discharged in an improved condition, tolerating a regular diet. Medications
included Tylox. He was
instructed in wound care and exercise restriction. He was passing his water,
passing gas from his rectum,
walking around. There was no evidence of significant hematoma or wound problems.5
He was asked to
return to my office in a week.
998 characters

2 Alternative: I could not advance the colonoscope . . .
3 The dictator says �I.� Edit the obvious misspeak to �he,� the patient.
4 The dictator stumbles here and corrects himself. Omit �what the problem is.�
5 Omit the redundant dictation, �He was instructed on wound care and exercise
restrictions,� from two lines above.

PROVISIONAL DIAGNOSIS
Kidney stone, left ureter.
FINAL DIAGNOSIS
Left ureteral stone, passed.
PROCEDURE
Cystoscopy, left retrograde pyelogram, ureteroscopy.
HISTORY
This patient was admitted to the hospital with acute ureteral colic on the left
side and obstruction at the
left ureterovesical (UV)1 junction on intravenous pyelogram (IVP).2
HOSPITAL COURSE3
The patient was observed, hydrated, and treated with analgesics for a few days to
see if the stone would
pass. It did not do so. Patient was still having some pain, and a cystoscopy, 4
left retrograde pyelogram,
and ureteroscopy were performed. The findings demonstrated no stone or
obstruction. The patient
presumably has passed the ureteral stone. Patient was discharged home and will
follow up in the office in
1 week.
794 characters
1 Expand an abbreviation on its first use and place the abbreviation itself within
parentheses.
parentheses. Alternative: Some
transcriptionists would not expand abbreviations for common x-ray studies.
4 The dictated brief form �cysto� should be expanded to cystoscopy.

ADMITTING DIAGNOSIS
Bladder outlet obstruction and urinary retention with lower urinary tract syndrome
(LUTS).1

The patient is an 80-year-old male who complains of incomplete urination, urinary
frequency, urgency,
hesitancy, and poor stream. This patient was in retention some 10-12 months ago
and required a catheter
for several days. His history is significant for a transurethral resection of the
prostate (TURP)3 for
retention 10 years ago for benign prostatic hyperplasia (BPH).4 His frequency,
urgency, nocturia, and
retention began about a year ago.
Evaluation in the office included an ultrasound of the bladder for postvoid

residual, which revealed a 377mL5
residual. PSA was 3.87. Symptoms have not improved with alpha blockers. AUA6 score
is 21. This
score is probably low based on the fact that the patient says he will not7 strain
to void. He will stand and
wait 15 or 20 minutes and try again. This would certainly accelerate that score.
The patient has considered the options and opted to undergo TURP. He stopped his
aspirin 5 days ago.

Significant for cataract surgery. He has had history of diverticulosis. He takes
stool softeners daily. He
weighs 164 pounds. He quit smoking 7 years ago. He drinks alcohol occasionally. He
is recently
widowed. He has 3 grown children.
FAMILY HISTORY
Family history is positive for heart disease, hypertension, but no prostate
problems.
ALLERGIES
PENICILLIN.
REVIEW OF SYSTEMS
As noted on the chart.
PHYSICAL8 EXAMINATION
GENERAL:9 Examination reveals well-developed, well-nourished male in no acute
distress.
HEENT: Reveals recent loss of a tooth. This tooth broke off at the gum line. He is
scheduled to have a
repair. Oropharynx, oral cavity unremarkable. Pupils equal, round, reactive to
light.
NECK: Supple without mass, megaly, or tenderness. There is no adenopathy or bruit.
There is no
supraclavicular adenopathy.
CHEST: Clear.
COR:10 Regular rate and rhythm without murmur.
ABDOMEN: Benign without mass, megaly, or tenderness.

GENITALIA: Phallus, meatus, scrotum, testicles, and cords unremarkable.
RECTAL: Anal tone and perineum normal. Prostate is 40 g11 without nodularity,
induration, or
asymmetry. Seminal vesicles are not palpated. Guaiac not indicated.
NEUROLOGIC:12 Neuro screen unremarkable.
ASSESSMENT 13
1. Urinary retention.
2. Bladder outlet obstructive symptoms.
3. Lower urinary tract syndrome (LUTS).
PLAN
Transurethral resection of the prostate (TURP).
2542 characters

itself within parentheses. Note: LUTS
can also stand for lower urinary tract symptoms. Syndrome was chosen in the
transcript because of the patient�s
chronic multiple urinary tract problems.
2 Expand an abbreviation used in a heading.
itself within parentheses. Alternative:
benign prostatic hypertrophy.
(milliliters).
6 AUA stands for American Urological Association, but the abbreviation does not
need to be translated because the
abbreviated form is actually the name.
8 The word physical was added to the heading for consistency in format.
10 Cor is the Latin word for heart.
11 Abbreviate units of measure, even if dictated in full, if they are accompanied
by a numeral.
12 Expand unacceptable brief forms in headings.
13 Enumerate diagnoses when there is more than one.

DISCHARGE DIAGNOSIS
1. Escherichia coli pyelonephritis.1

2. Asthma.
3. Herpes simplex type 1.
CONSULTATIONS
None.
PROCEDURE
Sonogram of kidneys.
SUMMARY
The patient is a 45-year-old white female who was treated approximately 10 days
prior to admission for a
urinary tract infection and started on an unknown antibiotic. Over the 2 days
prior to admission, the
patient noticed increased urinary frequency and burning with the onset of
bilateral flank pain and back
pain. This was associated with nausea and vomiting and inability to keep any type
of foods down. The
patient also has a history of �asthma� for which she will occasionally use a
Primatene inhaler. She does
smoke 2 packs per day of cigarettes.
On examination on admission, she showed evidence of moderately dry mucous

membranes, a temperature
of 99.8, a pulse of 108, respirations of 22, and a blood pressure of 110/70. Her
chest showed a few coarse
expiratory wheezes with good air movement. The heart was regular without murmur.
The abdomen was
soft and nontender without rebound or guarding. There was bilateral costovertebral
angle (CVA)2
tenderness, which was greater on the left than on the right.
Laboratory data was significant for a urinalysis showing a specific gravity of

1.015, positive ketones of a
moderate degree, white blood cells which were too numerous to count. Hemoglobin
was 12.5, hematocrit
of 37.8, with a white count of 12,100 with 67 polys and 1 band. A chest x-ray was
unremarkable.
The patient was admitted for pyelonephritis, started on IV fluid hydration and
Phenergan 50 mg IM q.6
hours3 for nausea. She was started on empiric antibiotic treatment with ampicillin
1 g IV
q.6 hours4 and gentamicin 100 mg IV load and 60 mg IV q.8 hours.5 Over the next
24-36 hours, the
patient defervesced.6 Blood cultures initially obtained were negative. A sonogram
was obtained to
evaluate the kidneys. This showed no evidence of perinephric abscess, ureteral
stones, or obstruction.
Urine culture obtained on admission came back growing greater than 100,000 E coli7
resistant to
ampicillin, however, sensitive to gentamicin and first-generation cephalosporins.
The ampicillin was
discontinued, and Ancef 1 g IV q.8 hours8 was started. The gentamicin was
continued for another 24
hours. The patient had some slight wheezing on admission which was relieved with a
Proventil MDI
inhaler9 2 puffs 4 times a day. The patient also had an outbreak of herpes simplex
type 1 around her lips
which was treated with Zovirax ointment. The patient at this time is tolerating
p.o. foods well. She has
markedly decreased CVA tenderness and is afebrile. The patient will be discharged
on Keflex 500 mg
p.o. q.6 hours10 for 5 days, Zovirax ointment q.i.d. to fever blisters, and
Proventil MDI inhaler11 2 puffs
q.i.d. The patient will follow up in my office within the next week after
antibiotic treatment is completed
for repeat urinalysis.
2911 characters
1 The dictated E coli should be expanded to genus and species name in full on
first use.
parentheses.
6 The dictated �defervesced� is commonly used to mean the subsidence of a fever;
it is a back-formation from the
noun defervescence.
7 It is customary to abbreviate the genus with the species, after it has earlier
been written in full. Alternative: E coli
(without a period after the genus abbreviation).
8 The dictator says �q 8.� Edit to q.8 hours (to match earlier forms).
Alternative: q.8 h. or every 8 hours.
9 MDI inhaler is redundant since MDI (metered-dose inhaler) includes the term.
10 The dictator says �q 6.� Edit to q.6 hours (to match earlier forms).
Alternative: q.6 h. or every 6 hours.
11 MDI inhaler is redundant since MDI (metered-dose inhaler) includes the term.

This 86-year-old white male was initially diagnosed as having an abnormal

prostate. He underwent an
open perineal biopsy at that time and was told he had no evidence of cancer. The
patient has had a long
history of progressive difficulty voiding. He complains of marked decrease in the
force and caliber of his
urinary stream and nocturia x3-4. The patient has a heavily trabeculated bladder
with an enlarged
occlusive prostate. Transrectal ultrasonography showed a volume of 31.9 mL1 with
poor bladder
emptying. Transrectal biopsy revealed a pathologic diagnosis of chronic
prostatitis and benign prostatic
hyperplasia. Urinary flow rate was markedly decreased at 3 mL/sec. Patient was
admitted for a
transurethral resection of his prostate.
Electrocardiogram showed a left anterior fascicular block, interventricular

conduction abnormality, and
frequent premature atrial beats. Chest x-ray demonstrated pulmonary fibrosis and
emphysema. Creatinine
of 1.7. PTT was normal. Hemoglobin was 12.6 g, white count 5600.
Patient was taken to the operating room, and under spinal anesthesia a
transurethral resection of his
prostate was accomplished; 17 g of tissue was2 resected which had a pathologic
diagnosis of benign
nodular hyperplasia. The patient�s postoperative course was uneventful. Following
removal of his Foley
catheter, he was able to void a good stream with full continence and no bleeding.
He was discharged
home on Macrodantin. He is to be seen in the office in 2 weeks for posthospital
followup.
1532 characters
1 The dictated �cubic centimeters� should be replaced with the SI equivalent mL

(milliliters).
2 The dictated �were� is edited to was for proper subject-verb agreement; metric
units of measure are always
considered singular.

CONSULTATION (2:30)
REASON FOR CONSULTATION

Perinephric abscess.
The patient is a 60-year-old woman with a year-long history of a psychotic

depression and recent
electroconvulsive therapy (ECT).1 She has an essentially negative past medical
history and has no known
allergies. Her husband cannot recall, nor can she, any episodes of fever, chills,
urinary tract infection,
cholangitis, etc., occurring ever in her life.
She began having fevers which spiked between 100 and 102 daily, and they have been
less than 101 since
that time, although she has continued a low-grade temperature.
Interestingly, even with her higher temperatures, she had only rare episodes of
tachycardia. An extensive
evaluation has included a normal chest x-ray, thyroid functions, lung scan,
echocardiogram. Blood
cultures obtained were negative. Urine culture was negative. She has had normal
urinalyses on 3
occasions. She has a normal white count and differential and hemoglobin of 12.7,
sed rate of 96. A
gallium scan showed a hot right kidney, and a CT scan showed a rather large right
perinephric abscess.
Yesterday2 this was aspirated, and 4 mL3 of pus was obtained. The Gram stain
showed many polys. So far
the culture is negative. She was started on ampicillin at 1 g every 6 hours and
Tobramycin 70 mg every 8
hours. Other medications include Xanax 1 mg t.i.d., lecithin 1.2 g t.i.d., Inderal
20 mg b.i.d., and
Surmontil 250 mg per day.
On exam a pleasant but rather stiff woman in no acute distress. She answers slowly
but appropriately. She
has an essentially normal exam. There is no costovertebral angle (CVA)5 tenderness
to palpation or fist
percussion. No abdominal masses.
IMPRESSION
1. Perinephric abscess.
2. Psychotic depression.
DISCUSSION
The most likely organisms for perinephric abscesses are aerobic gram-negative
rods. I would postulate
that she must have had a bacteremia at some point with secondary seeding of the
perinephric space. A
likely source in this situation is obviously the urine or perhaps an episode of
cholangitis. She could have
had a �silent� pyelonephritis in the past, but I doubt this.

I agree with the ampicillin and Tobramycin for the moment.
The abscess is really quite large on the CT scan and will need drainage of some
sort. I plan on repeating
the CT scan, and I think it is reasonable to make an attempt at catheter drainage.
The only alternative is an
open procedure.
I appreciate your referral and will follow along with you.
2468 characters
parentheses.
3 The dictated abbreviation �cc� is on the list of dangerous abbreviations and
should be replaced with its SI
equivalent mL (milliliters).
parentheses.

This is a 25-year-old white female who is 4-1/2 months pregnant, who complains of
severe right flank
pain, fever, and vomiting since last night. Patient noted that she had a fever to
104 this morning. Does
note some lower abdominal and leg crampiness. The patient has noted urinary
frequency over the past 3
days. Patient has a history of frequent urinary tract infections (UTIs).1 She is
gravida 7, para 3, ab 3. She
is unsure of her last menstrual period. She denies any history of surgery. She
denies any medical
problems such as diabetes or hypertension. She denies any history of low blood
pressure as well. Her only
medications are prenatal vitamins.
GENERAL:3 The patient is a 25-year-old white female in moderate distress.
VITAL SIGNS: Orthostatic vital signs revealed blood pressure 112/64, pulse of 140
supine, and a blood
pressure of 78/64 and a pulse of 160 standing, with severe dizziness. Patient
developed an acute episode
of shivering and spiked a temperature of 104.6 with a pulse of 160 and a
respiratory rate of 36. Blood
pressure was 104/60.
SKIN: Hot and dry.
NECK: Neck is supple.
LUNGS: Lungs are clear.
HEART: Heart tones reveal a regular rhythm with no rubs or murmurs.
ABDOMEN: Abdomen reveals normal bowel sounds. It is soft with no tenderness. The
uterus is palpable
at about a 4-1/2-month size. There is marked right costovertebral angle (CVA)4
tenderness and very slight
left CVA tenderness.
PELVIC: The Bartholin�s,5 urethral, and Skene�s6 glands are normal. The os is
closed with a scant yellow
discharge. A cervical culture was sent. There is no cervical motion tenderness.
The adnexa are negative
for any masses or tenderness.
EXTREMITIES: Extremities reveal no clubbing, cyanosis, or edema.
NEUROLOGICAL: Neurologically she is alert and oriented.
LABORATORY DATA
White count 12.8 with 51 polys, 32 bands. Hemoglobin 11.6, hematocrit 33.9. Sodium
134, potassium
3.7, chloride 105, bicarb 22. Glucose 111. BUN 7. Creatinine normal. Urinalysis
revealed too-numerousto-
count white cells and 4+ bacteria as well as large ketones. Culture and
sensitivity was sent. No white
cell casts were noted. Blood cultures x2 were obtained.
DIAGNOSIS
1. Right-sided pyelonephritis with marked dehydration and borderline sepsis.

2. Intrauterine pregnancy at approximately 4-1/2 months.
2349 characters

parentheses.
parentheses.
5 Alternative: Bartholin. The use of the possessive form of eponyms is acceptable
6 Alternative: Skene. The use of the possessive form of eponyms is acceptable when
it is dictated or when it is

A 55-year-old male who is referred for left varicocele and patent processus
vaginalis and possible left
renal abnormality. The patient most recently has had problems with Peyronie�s1
disease and has had
treatment with Potaba and injection therapy with intralesional steroids without
any resolution in the
problem. The patient has significant curvature and pain on erection but is still
getting erections. He is
advised that surgical removal of the plaque may result in impotence and has been
offered implantation
simultaneously of a penile prosthesis but has deferred this and wishes to see if
the excision of the plaque
alone will be sufficient. The patient is also advised of the possibility of injury
to the blood vessels and
nerves of the penis and immobilization of the neurovascular bundle. The patient is
being admitted for
excision of the Peyronie�s plaque on the penis.

Positive for automobile accident which left him with a damaged left leg and has
had 3 knee fusions and
has a stiff leg secondary to this and some resultant scoliosis. Patient has been
hypertensive.
REVIEW OF SYSTEMS
Negative.
SOCIAL HISTORY
Married. Self-employed. Has 4 children. Nonsmoker, nondrinker.
FAMILY HISTORY
Family history of hypertension and heart disease.
GENERAL:3 Physical exam reveals a well-nourished male in no acute distress.
HEENT: Pupils equal, round, react to light. Ears, nose, and throat clear.
NECK: Supple.
LUNGS: Clear to percussion and auscultation (P&A).4
HEART: Regular rhythm. No murmur.
ABDOMEN: Soft, nontender. No mass or organomegaly. No costovertebral angle (CVA)5
masses or
tenderness.
NEUROLOGICAL: Neurologically oriented x3 with no gross deficit.
PENIS: Firm plaque on the dorsum of the penis in the distal shaft. Unresponsive to
Potaba, intralesional
steroids, and vitamin E therapy.
RECTAL: Grade 1/4 prostate. No induration or tenderness. Testes bilaterally
descended. Left varicocele.
IMPRESSION
Peyronie�s disease of penis.

RECOMMENDATION
Excision of Peyronie�s plaque and graft to penis.
2114 characters
1 Alternative: Peyronie. The use of the possessive form of eponyms is acceptable

parentheses.
parentheses.

This 62-year-old white male has had a long history of urethral stricture disease,
which the patient states
dates back to childhood when he had his urethra dilated. Patient states he was
born with a water-bottle
kidney, which was removed. He had a tube graft urethral reconstruction done.
Patient has continued to
have difficulty with his stricture, having intermittent dilations. Cystoscopy and
internal urethrotomy were1
done. He has reformed his stricture.2 A retrograde urethrogram demonstrates a 2-
cm, narrow distal bulbar
stricture. The patient was admitted at this time for KPT laser destruction of his
urethral stricture.
PAST HISTORY
He had a nephrectomy 20 years ago. He has had an appendectomy. He takes no
medication regularly.
There are no known drug allergies.
SOCIAL HISTORY
He works for the public school system. He is married.
FAMILY HISTORY
Noncontributory.
REVIEW OF SYSTEMS
Neuromuscular: Denies vertigo, syncope, convulsions, headaches, muscle or joint
pain.
Cardiorespiratory: Denies shortness of breath, dyspnea on exertion, chest pain,
cough, or hemoptysis.
Gastrointestinal:3 Denies emesis, melena, constipation, diarrhea, or rectal
bleeding.
Genitourinary:4 Refer to History of Present Illness.
VITAL SIGNS: Pulse is 52 and regular, respirations 18 and regular. Blood pressure
is 120/70.
GENERAL: Well-developed, well-nourished white male in no acute distress. Alert and
cooperative.
HEAD, EYES, EARS, NOSE, AND THROAT: Pupils are equal, round, react to light and
accommodation. Extraocular movements are intact. Pharynx is clear.
NECK: Neck is supple. No thyromegaly. No cervical adenopathy.
CHEST: Chest is symmetrical with equal expansion.
LUNGS: Lungs are clear to percussion and auscultation.
HEART: No cardiomegaly. No thrills or murmurs. Normal sinus rate and rhythm.
ABDOMEN: Abdomen is flat, soft, and nontender. Liver, spleen, kidneys, and bladder
are not palpable.
There is no guarding or rebound tenderness. Bowel sounds are normal.
EXTREMITIES: No peripheral edema or varicosities.
GENITALIA: Normal external male genitalia. No penile lesions. Testes are descended
bilaterally and are
normal to palpation.
RECTAL: The prostate is approximately 20 g in size, benign, and nontender.

IMPRESSION
Recurrent bulbar urethral stricture.
2307 characters
1 Edit the dictated was to were for proper subject-verb agreement.

2 Edit for accuracy. Alternative: His stricture has reformed.
3 Expand abbreviations used in headings.
4 Expand abbreviations used in headings.

HISTORY
This patient is a 62-year-old Caucasian male. He has recently moved to the area.
He is now admitted to
the hospital because of evidence of renal failure1 and anemia.
History reveals that this patient has had a history of cerebrovascular

arteriosclerosis. He has also had a
long-standing history of hypertension. He apparently had a cerebrovascular
accident. He had a left carotid
endarterectomy which went without incident. Then during the process of a right
carotid endarterectomy,
he apparently developed a right hemispheric cerebrovascular accident (CVA)2
resulting in permanent left
hemiparesis. However, aside from this unfortunate problem, he has done well. He
continues with left
hemiparesis and hypertension, but these have been well controlled. To his
knowledge he has not had any
significant recent problems.
He was recently seen by myself in the office and was noted to have evidence of
chronic renal
insufficiency. He was also noted to have anemia. He is therefore being admitted to
the hospital for further
workup of his chronic renal insufficiency, recent diarrhea, and hemoglobin of 9.2.
He denies any known previous history of renal failure or renal insufficiency. Did
have hematuria, but no
etiology was given. He denies any known history of nephrolithiasis,
glomerulonephritis, or other forms of
renal failure. He has no known history of diabetes mellitus.
He has had anemia in the past, but no etiology was given. To his knowledge he has
had no recent anemia.
No history of multiple myeloma. He has no known history of GI bleeding. No history
of neoplasm.
His BUN on admission is 75, and his creatinine is 6.3.
PAST HISTORY
Allergies: He is allergic to sulfa.
Medications:3 Medications at the time of admission included hydroxyzine 25 mg
p.r.n. itching,
furosemide 40 mg b.i.d., propranolol 80 mg b.i.d., Theragran-M, and an
antidepressant.
Surgical History: Surgical history includes tonsillectomy and adenoidectomy,
previous endarterectomy as
noted above.
Medical History: Medical history negative for epilepsy. Positive for stroke as
above. Negative for thyroid
disease or diabetes mellitus. Positive for hypertension. No previous history of
arteriosclerotic heart
disease (ASHD),4 myocardial infarction or congestive heart failure, or valvular
heart disease. Positive for
chronic obstructive pulmonary disease. Positive for pneumonia. No history of
pulmonary embolism. No
previous history of peptic ulcer disease, hepatitis, or colitis. Previous history
of hematuria, but no history
of renal insufficiency or renal failure. No history of inflammatory arthritis or
gout.

REVIEW OF SYSTEMS
Central Nervous System:5 He denies any recent change in his paresis or paralysis.
Cardiovascular: He denies any recent chest pain, orthopnea, paroxysmal nocturnal
dyspnea (PND),6 or
exertional chest discomfort. Has been having some ankle edema. No palpitations.
Respiratory: He denies any cough, hemoptysis, or pleurisy. He does have occasional
wheezing which
recently has improved.
Gastrointestinal: He has had recent anorexia, nausea, but no vomiting. He has had
some loose stools.
However, no hematemesis, melena, or hematochezia. Has also had some recent weight
loss.
Genitourinary: He denies any dysuria or hematuria. Has had some difficulty
urinating.
Musculoskeletal: He denies any unusual arthritis or arthralgias.
GENERAL: Physical exam reveals an alert, cooperative Caucasian male who appears
somewhat pale.
However, he is nondiaphoretic and nonicteric.
EYES: Pupils equal, round, and reactive to light. Extraocular movements intact.
Funduscopic exam
reveals no papilledema. No unusual retinopathy.
MOUTH: No unusual mucosal lesions. He has upper and lower dentures.
NECK: Evidence of previous carotid surgery. No bruit is heard at the present time.
No thyromegaly or
neck masses or adenopathy.
LUNGS: Lungs show mild wheezes bilaterally. There are a few fine rales in the
right base, but otherwise
his lungs are clear. He is neither dyspneic nor tachypneic. No rubs.
HEART: Heart sounds are regular, but the heart sounds are distant. S1 and S27 are
normal. No significant
murmur, gallop, or rub.
ABDOMEN: The abdomen is obese and mildly distended. However, no apparent
organomegaly or
masses. Bowel sounds normal. No bruit. No aneurysmal dilatation.
EXTREMITIES: He has 1 to 2+8 pretibial edema bilaterally. Femoral pulses 2+
bilaterally. Popliteal
pulses 1+ bilaterally. Questionable dorsalis pedis pulses bilaterally. No
Babinski�s.9 He is slightly
hyperreflexic on the left side.
IMPRESSION10
1. Renal insufficiency, probably chronic.

a. Rule out obstructive uropathy.
b. Rule out glomerulonephritis.
c. Rule out hypertensive nephrosclerosis, most likely.
2. Anemia, probably on the basis of chronic renal failure.11
a. Rule out dysproteinemia.
b. Rule out iron deficiency.
c. Rule out mixed anemia.
d. Rule out hematologic malignancy.
3. Chronic obstructive pulmonary disease, stable.
4. History of cerebral arteriosclerosis.
5. Hypertension.
This patient will be admitted to the hospital. His anemia and renal failure will
be worked up. Would
anticipate that he may well need dialysis and nephrology consultation.

5188 characters
1 Omit incorrectly dictated comma.

parentheses.
parentheses.
5 Expand abbreviations in headings.
parentheses.
7 Alternative: S1 and S2.
8 Alternative: 1+ to 2+.
9 Alternative: Babinski sign. The use of the possessive form of eponyms is
acceptable when it is dictated or when it
is preferred by the employer or client.
10 Transcribed in outline format as dictated. On the job you would check with the
client to be sure that the indented
outline form can be transmitted electronically without the format changing.
11 Outline style is continued for consistency in format; letters a, b, c, d are
added.

DISCHARGE DIAGNOSIS
1. Bilateral staghorn calculi.1

2. Quadriplegia.
3. Decubitus ulcers.
4. Urinary tract infection.
HISTORY
This is a 37-year-old white male, C4-5 quadriplegic secondary to motor vehicle
accident, who has
bilateral staghorn calculi filling the whole left renal pelvis, the right a
smaller amount of stone within the
pelvis. The patient was admitted to the hospital for evaluation of this problem
and extracorporeal shock
wave lithotripsy (ESWL).2
LABORATORY DATA3
The patient preoperatively had a creatinine of 0.6,4 his white count 6500.
Coagulation studies were
normal. Urinalysis showed greater than 200 white cells, 15 red cells, and calcium
phosphate crystals.
Culture of the bacteria5 grew out klebsiella and pseudomonas.
HOSPITAL COURSE
The patient had a ureteral stent placed and underwent ESWL. There were multiple
fragments seen within
the right kidney the following day, and he was discharged home approximately 2
days later. He was sent
home on Bactrim and asked to have a repeat KUB in 7-10 days to ascertain his
progress. The left stone
will have to be handled later after the right kidney is cleared of stone. The
question is whether we should
do ESWL multiple times on the left kidney or whether we should consider doing an
open
nephrolithotomy.
1279 characters
1 Number the diagnoses when there is more than one.

parentheses.
5 Insert �Culture of� for accuracy. The bacteria did not grow out the bacteria.

PRINCIPAL DIAGNOSIS
Torsion of the left testicle.
OPERATIONS AND PROCEDURES

Scrotal exploration, detorsion of left testicle, and bilateral orchiopexy.
HISTORY1
This 12-year-old black male presented after the sudden onset of suprapubic
abdominal pain about 6 hours
prior to admission. This was followed by several episodes of emesis and the onset
of left testicular pain.
There was no history of trauma. The patient denies previous similar episodes. The
patient denies urinary
symptoms or hematuria. Additionally the patient experienced 2 episodes of loose
stools.

Past medical history is significant for the usual childhood illnesses. He has had
no previous surgery. No
major medical problems.
MEDICATIONS2
No medications at the time of admission.
ALLERGIES
No known drug allergies.
SOCIAL HISTORY3
The patient lives with his parents and attends school.
FAMILY HISTORY
Noncontributory.
REVIEW OF SYSTEMS
Noncontributory.
GENERAL: Well-developed, well-nourished black male who is lying comfortably in
bed.
VITAL SIGNS: He is afebrile. His pulse is 92, blood pressure 110/78, respiratory
rate 28, weight
48 kg.
HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light and
accommodation.
Extraocular muscles intact. Sclerae are clear. Mucous membranes are moderately
dry.
NECK: Neck is supple without adenopathy.
CHEST: The chest is clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm.

ABDOMEN: Abdomen is soft, nontender. There are no palpable masses or
hepatosplenomegaly. Bowel
sounds are normoactive.5
GENITOURINARY: There is a golf ball-sized left scrotal mass which is exquisitely
tender. The mass is
indistinguishable from the testicle and appears to lie6 in a horizontal position.
The inferior portion of the
scrotum transilluminates. The superior portion does not. The cord structures are
palpable. There is no
evidence of hernia. The right testicle is within normal limits.
RECTAL: Rectal examination reveals good tone. Heme-negative mucus and stool.
NEUROLOGICAL: The neurological exam is physiological.
LABORATORY
Hemoglobin is 14.3, hematocrit 42.0. White count 5800,7 53 segs, 39 lymphs, 8
monos. Sodium 137,
potassium 3.9, chloride 103, bicarbonate 28. BUN 6, creatinine 0.8.8 Glucose 121.
The remainder of the
profile is within normal limits.
HOSPITAL COURSE9
Pediatric surgery consultation was obtained, and after our evaluation we suspected
torsion of the left
testicle. Therefore the patient was admitted to the hospital and taken to the
operating room for scrotal
exploration. At that time the left testicle was congested and cyanotic and was
consistent with torsion;
however, it appeared viable. Therefore it was not removed, and bilateral
orchiopexy was performed. The
patient did well during the postoperative period, remained afebrile, began eating
on the evening of
surgery, and by the time of discharge on the 1st postoperative day, the patient
was taking p.o. liquids and
solids well. Bladder function was intact. The scrotum was mildly swollen but not
tense. The incision was
clean and dry, and the patient was ambulatory. At the time of discharge,
instructions were given regarding
wound care and diet and activity. The patient was instructed that he could resume
his usual diet at home.
He should refrain from strenuous activity until further notice and should refrain
from riding bicycles or
straddling activity. He may take showers and should wear an athletic supporter or
scrotal support.
CONDITION AT THE TIME OF DISCHARGE

Good.
PROGNOSIS
Prognosis is excellent, although the left testicle may eventually atrophy and be
nonfunctional. The patient
was scheduled for followup appointment in the outpatient pediatric surgery clinic.
3776 characters

1 Omit redundant heading �and physical examination.�
2 Headings are added for consistency in format
3 The next several paragraphs could be incorporated in the past medical history in
narrative format.
4 Alternative: A narrative format could be used for the physical examination.
5 Normoactive
is medical jargon and a common medical term, applying not only to bowel sounds but
also to deep
tendon reflexes and children who are not hyperactive.
6 Edit lay to lie for correct usage.

HEENT DICTATION #1
OFFICE NOTE (1:00)
SUBJECTIVE
Patient is a 4-year-old Caucasian male here for recheck of ears. He completed a
10-day course of
Augmentin. Has continued to pull at his ears; however, there has been no fever or
fussiness. Activity level
is normal.
OBJECTIVE
General: Awake, alert, active male child in no apparent distress. Tympanic
membranes are bilaterally
erythematous and dull, left greater than right. Nares are patent. Mouth: There is
poor dentition. Throat is
clear. Neck is supple without adenopathy.
IMPRESSION
1. Resolving bilateral otitis media.

2. Dental caries.
PLAN
1. Patient will complete a 14-day course of Augmentin and have his ears checked in
2 weeks.
2. Have advised mother to encourage patient to be brushing teeth after every meal.
743 characters

HEENT DICTATION #2
OFFICE NOTE (0:30)
SUBJECTIVE
Patient is here today for followup. She was treated with 2 weeks of amoxicillin
for chronic sinusitis. She
states that she is doing much better and that she has no more dizziness and no
more headaches. She still
has allergic symptoms from time to time including itchy eyes, sneezing, and
rhinorrhea.
OBJECTIVE
Face: No facial tenderness.
ASSESSMENT
Chronic sinusitis, resolved.
PLAN
Because of the chronicity of this problem, will treat with 1 more week of
amoxicillin.
494 characters

HEENT DICTATION #3
OFFICE NOTE (1:00)
HISTORYA2 6-month-old male here for visit today. The child has been having cough
and runny nose for a week to
2 weeks with significant rhinorrhea. No noticeable fever and no noticeable pulling
at his ears. He has
been eating well and acting normally at home.
The child is afebrile, 98.9. Is in no apparent distress. Well-appearing 6-month-
old. HEENT exam: No
conjunctival erythema or discharge is noted today. Ears reveal mild erythema
bilaterally with some
bulging of the tympanic membranes. No discharge in the external canals noted.
Pharynx is mildly
erythematous without significant tonsillar enlargement. Lungs are clear to
auscultation with some
transmitted upper airway noise. He has some crusted nasal discharge. Abdomen is
soft and nontender.
Cardiac is regular rate and rhythm without murmur.
ASSESSMENT
A3 6-month-old with upper respiratory infection and mild bilateral otitis media.
PLAN
Will treat with amoxicillin, Tylenol, Rondec. Will see him back in 2 weeks for
recheck, sooner if his
symptoms worsen.
1053 characters
1 Headings are added for consistency in format. Alternative: SUBJECTIVE.

2 A was added to avoid starting the sentence with a numeral.
3 A was added to avoid starting the sentence with a numeral.

HEENT DICTATION #4
OFFICE NOTE (1:30)
He had some right ear pain and drainage and has a history of recurrent otitis
media. He also had an
abnormal hearing test in the right ear. He failed the entire screening on the
initial screen. Subsequently he
passed on the hearing screen but failed the tympanometry. Mother states that this
time he had some right
ear pain and some drainage from the external ear canal which has been yellowish.
OBJECTIVE
Ears bilaterally show evidence of former tube placement with some scarring. The
left ear appears to be
clear without fluid. The right ear has a fluid behind it and is slightly
retracted. No evidence of erythema.
There is a yellowish drainage from earwax but no erythema in the canal and no
evidence of an open
tympanic membrane. Sclerae are white. Nares erythematous and very swollen,
particularly on the right
side. Oropharynx clear. Neck: Supple, no lymphadenopathy.
ASSESSMENT
Right ear drainage consistent with earwax. Also, right ear tympanometry failure,
most likely secondary to
serous otitis.
PLAN
Treat with Beconase inhaler to assist with nasal and nasopharyngeal drainage. The
child to follow up in
about a month. I have made a request that the school retest his tympanometry in
about 3-41 weeks. If at
that time it is abnormal, they should attempt to make a referral to an ENT
physician. The mother also
brings up that the child seems to be very �hyper� and wishes to have a behavior
evaluation. This would
probably start with a more complete history in 1 month.
1495 characters
Alternative: 3 to 4 weeks.

HEENT DICTATION #5
OFFICE NOTE (2:00)
SUBJECTIVE:1
This is a 15-year-old Hispanic male. He has been complaining of a headache for the
past week which has
been intermittent. He describes this headache as being bitemporal, comes on toward
the end of the day.
Does have associated photophobia and associated nausea without any vomiting. The
patient does have a
family history of migraine headaches and has a past history of headaches for which
he has been treated
with Inderal in the past. The patient states that he does take Tylenol, but it
does not2 seem to help. His
mother brings him in today because for the past several days he has had complaints
of a sore throat and
generalized fatigue. The patient has no known exposure to strep or mono. He denies
any history of fever.
He has stayed home from school for the past 3 days because of the generalized
fatigue, sore throat, and
headache.3
In terms of the patient�s social history, he is a 10th grader. He is an above-

average student and denies any
stress at home or at school.
OBJECTIVE
Vital signs as above.4 HEENT: Normocephalic, atraumatic. Pupils were equal and
reactive to light.
Funduscopic exam revealed sharp disks bilaterally. Tympanic membranes were
nonerythematous.
Oropharynx revealed mild erythema without any tonsillar enlargement or exudates.
Neck was supple.
There was no lymphadenopathy or thyromegaly. Full range of motion without any
meningeal irritation.
Lungs clear to auscultation. Cardiovascular exam: Regular rate and rhythm without
any murmur.
Neurologically cranial nerves 2-12 were intact. Reflexes were 2+ bilaterally,
symmetrical. Motor strength
was 5/5. Gait was within normal limits. Abdominal exam revealed no splenomegaly,
no hepatomegaly.
ASSESSMENT
1. Pharyngitis and associated fatigue. I believe that this is probably due to a

viral illness and is unlikely to
be streptococcus5 or mononucleosis;6 however, at this point I will do tests to
further work that up.
2. Headache, probably a combination of both migraine and tension headaches.
PLAN
At this point I have suggested symptomatic treatment for the headaches with rest,
avoidance of light, and
Tylenol p.r.n. In terms of his viral illness, I will at this point go ahead and do
a throat culture to make sure
he does not have strep throat, as well as sending him off to the lab to get a mono
test and a CBC.
Otherwise mother was told to treat symptomatically. The child is to follow up in 2
weeks if he is not
better.
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3 A new paragraph is appropriately added before the social history.
4 The dictator is referring to a sheet in the chart where the vital signs were
recorded by hand; no doubt this report
would be printed on sticky-back paper and pasted in below the handwritten notes.
5 Expand the dictated brief form strep in the assessment or diagnosis.
6 Expand the dictated brief form mono in the assessment or diagnosis.

HEENT DICTATION #6
OFFICE NOTE (1:00)
SUBJECTIVE1
This is a 15-month-old white female who is here for followup of bilateral otitis
media, status post ear tube
placement. At that time she was placed on Augmentin 125 mg t.i.d. At the time that
she presented, she
was not having any fevers or chills but was tugging at her ear, and mom had
noticed a little bit of a
drainage from one of her ears. Since she has been on the antibiotics, she has not
noticed any other
drainage at all. Otherwise, the child is acting normal and healthy.
OBJECTIVE
Normocephalic. There was a slight scar below her right eye from where mother
states that she fell and hit
the coffee table. Tympanic membranes: Left TM was occluded with cerumen, but after
the cerumen was
taken out, one could see the tube in place. Position was difficult to determine.
The ear did still look
erythematous and slightly bulging. Right tympanic membrane again revealed no
bulging but was
erythematous. Ear tube appeared to be in place and draining well. Oropharynx was
nonerythematous.
Lungs clear.
ASSESSMENT2
1.
Bilateral otitis media, currently status post Augmentin therapy, still with
persistent erythema.
2.
Status post ear tube placement. I do have some question as to whether or not the
tube in her left ear is
draining adequately.
PLAN
At this point I will go ahead and put the child on Septra 1 teaspoon p.o. b.i.d.
for 103 days. She is to
follow up with me in 2 weeks� time.
1408 characters

2 Number diagnoses when more than one is listed.
as for rather than using times or x.

HEENT DICTATION #7
A1 13-year-old child with long-standing history of chronic adenotonsillitis,

unresponsive now to medical
management. The patient�s preop lab was unremarkable. She had an
adenotonsillectomy under general
anesthesia with no postop complications. The morning following surgery, she is
afebrile. No obvious
source of postoperative problems. Will be discharged to be seen in my office in 1
week.
POSTOPERATIVE2 DIAGNOSIS
Chronic tonsillitis with adenoidal and tonsillar hypertrophy.
SURGICAL PROCEDURE
Adenotonsillectomy.
Tylenol with Codeine elixir3 as well as penicillin VK 250 mg oral suspension for
the next 10 days.
657 characters
1 Alternative: This is a . . .
3 The correct brand name is Tylenol with Codeine; the form of administration
should come after the name of the
drug.

HEENT DICTATION #8
OFFICE NOTE (2:00)
DIAGNOSIS
Breathing obstruction secondary to posterior septal deviation.
HISTORY
A 26-year-old white female who presentedwith complaints of bilateral breathing

obstruction. The
patient denies any recent nasal trauma, although had a vague recollection of
undergoing a sports injury as
a child with nasal trauma but with no nasal x-rays or medical workup at that time.
On physical examination the patient was found to have a broad nasal dorsum with a
slight curvature of the
nose to the left. Intranasal exam was significant in that there was an obvious
septal deviation with the
caudal portion of the septum resting in the left vestibule but with the 100%
obstruction of the right nasal
vestibule in the posterior aspect of the nose. There was an additional 50%
obstruction in the posterior
aspect of the left vestibule. Bilateral inferior turbinates were hypertrophied due
to an allergic rhinitis. The
patient had a persistent obstruction of the right airway and a 50% obstruction of
the left airway.2
It was felt that the patient would obtain marked functional improvement of her
breathing by performing a
septoplasty as well as a rhinoplasty that would realign the nasal dorsum into the
midline. Patient was also
placed on Keflex 500 mg 1 tab p.o. q.i.d. preoperatively as well as for 1 week in
the postoperative period
due to the patient�s history of mitral valve prolapse.
PROCEDURE
Septorhinoplasty with submucous resection of posterior septum and partial
resection of perpendicular
plate of the ethmoids.
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1 Alternative: This 26-year-old white female presented . . .�

2 New paragraphs are inserted to separate the sections of the report
appropriately.

HEENT DICTATION #9
The patient is an 80-year-old white male, Spanish-speaking, who has been1 admitted
with dehydration,
fever, chills, and exudative pharyngitis.
HOSPITAL COURSE
The patient was admitted to the medical floor where he was hydrated with IV fluids
and also cultured and
started on IV antibiotic treatment. His temperature was 100.8 to being afebrile
with vital signs within
normal limits. He was started on p.o. fluids which he tolerated fairly well and
was advanced to a general
diet. His electrolytes were normal. His chemistry profile was essentially within
normal limits. The
patient�s urine showed an increase of specific gravity consistent with his
dehydration. There was
moderate and then trace urine blood which at this time is being followed up as an
outpatient. The cultures
did not show any specific pathogen. Chest x-ray was normal. Patient did complain
of frontal headaches.
The sinuses did show some slight prominence of the inferior turbinates, but no
other problem was noted.2
Patient did have an IVP done in order to evaluate the3 slight amount of blood in
the urine, and that was
negative.
He continued to improve, although the headaches did persist, and was then sent
home to be followed up
as an outpatient. There were no other complications or problems during the
hospitalization.
FINAL DIAGNOSIS
1. Exudative pharyngitis.
2. Dehydration.
3. Hematuria, probably idiopathic.
4.4 Headaches, likely secondary to the above problems.
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1 Edit �is being� to �has been� or �was� admitted, since this is a discharge
summary.
2 New paragraphs are inserted to separate the sections of the report
appropriately.
3 Edit the pronoun his to the article the for proper usage.
4 Correct misdictated numbers.

HEENT DICTATION #10
FINAL DIAGNOSES
1. Epistaxis, left, posterior.

2. Platelet function defect, secondary to aspirin.
3. Cancer of lung.
4. Essential hypertension.
SUMMARY
A1 59-year-old gentleman was admitted to the hospital following 3 episodes of
bleeding from the left side
of the nose. He was on antihypertensive medications. Had had a thoracotomy
approximately
1-1/2 weeks previously for adenocarcinoma of the lung. Because of a suspicion of a
left posterior
epistaxis, the patient also admitting to using aspirin, he was admitted to the
hospital for sedation and
observation.
He had a history of allergy to penicillin. He was seen in consultation by his

internist on admission to the
hospital. The patient remained relatively stable. However, he had 2 episodes of
bleeding while in the
hospital. The platelet aggregate studies were abnormal, indicating interference
due to aspirin-like
compounds. When the patient had his 2nd episode of bleeding in the hospital, it
was elected to explore the
nasal cavity and nasopharynx under general anesthesia. This was carried out under
general anesthesia.
There appeared to be a bleeding site at the posterior end of the left inferior
turbinate. Using a transnasal as
well as a transoral nasopharyngeal approach, using laryngeal mirrors, the bleeding
site was controlled
with cautery. Several other areas in the nose were cauterized as well. These may
have been related to
trauma from the suction tip and instrumentation of the nose. His postoperative
course was satisfactory.
Postoperatively his blood pressure still remained a little bit high. Packs were
removed from the left side of
the nose on the 1st postoperative day. The patient was begun on ambulation. He was
discharged from the
hospital. Was to be seen for followup visits. It was elected not to restart his
aspirin, Persantine, or
Maxzide at the present time.
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1 The article A is added to avoid starting the sentence with a numeral.

Alternative: This.

HEENT DICTATION #11
FINAL DIAGNOSIS
Acute cellulitis and abscess of nose.
SUMMARY
This1 9-year-old male was admitted through the emergency room after he presented
for the second time
because of increasing cellulitis, swelling, and pain involving the nose and
central portion of the face. As
an outpatient he had been started on Ceclor 250 mg t.i.d. He had returned to the
emergency room on the
evening of the day of admission because of greater swelling, temperature of 100.9,
and more swelling and
tenderness. A diagnosis of facial cellulitis secondary to nasal vestibulitis was
made. Patient was admitted
to the hospital. Cultures of blood and of the nose were obtained. Nasal cultures
grew out Staphylococcus
aureus, coagulase-positive. He was begun on Zinacef because of its cerebrospinal
fluid (CSF)2
penetration and admitted for close observation. The temperature remained elevated.
Clinically he began to
improve. The culture and sensitivity results, however, were somewhat questionable.
It was thought that
the sensitivity results were spurious, and the laboratory was advised of this and
was planning to repeat
sensitivity testing. The patient�s abscess localized and began draining from the
anterior portion of the
right nasal vestibule. He was taken to the operating room where, under general
anesthesia, incision and
drainage of the nasal abscess was carried out. A small length of iodoform gauze
was placed into the
abscess cavity and fell out spontaneously on the following morning. His
temperature remained afebrile.
He was continued on nafcillin intravenously until the time of discharge. Discharge
medications included
Dynapen 125 mg q.i.d. for an additional 7 days and Polysporin ointment inside the
nostril. He was to be
seen in my office approximately 1 week to 10 days post discharge.
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1
Add This or An to avoid beginning the sentence with a number.
Expand an abbreviation on its first use and place the abbreviation within
parentheses.
HEENT DICTATION #12
She has had a blind eye with only light perception vision following trauma to the
left eye. She has
undergone multiple surgeries and has no potential for useful vision in the eye.
She has on numerous
occasions requested that the eye be removed, recognizing that there is no
potential for vision in the eye.
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HEENT DICTATION #13
FINAL DIAGNOSIS
Retinal tear, right eye.
This 74-year-old male, with symptoms of floaters and flashing lights in the right
eye for 3 weeks, was
found to have a horseshoe-shaped retinal tear without detachment or with very
shallow detachment at the
12 o�clock position. Visual acuity was 20/40 in the right eye and 20/50 in the
left. Intraocular tensions
were normal. There was no other ocular abnormality with the exception of
cataracts.
HOSPITAL COURSE
Hospital course consisted of cryopexy of the retinal tear under general
anesthesia. There were no
operative complications. The patient is discharged to home and will be followed as
an outpatient.
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HEENT DICTATION #14
OFFICE NOTE (1:30)
The patient is a 22-year-old female who has been suffering from a blind, painful
eye for several years.
She has been blind in the left eye for 10 years, presumably from a retinal
detachment which was
unsuccessfully repaired. She now has significant pain every day and wishes to have
the eye removed. At
the time of my exam, her best corrected visual acuity was 20/20 in the right eye
and light perception in
the left eye only.1 The conjunctiva of the left eye was 4+ injected. The tension
by applanation was 16
mmHg2 in the right eye and 0 in the left. Anterior chamber of the left eye showed
organization of vitreous
with blood vessels growing into the interior of the vitreous body. Examination of
the retina of the right
eye showed a normal retinal contour. She is going to be scheduled for enucleation
of the left eye with
implant of a hydroxyapatite sphere. She had what sounds like a fluorescein
angiography a few months
back, but she does not know the results of this.
993 characters
1
The sentence can be recast to move the adjective only in front of the word it
modifies as follows: �only light
perception in the left eye,� or �light perception only in the left eye,� etc.
Alternative: mm Hg.

HEENT DICTATION #15
HISTORY OF THE PRESENT ILLNESS

Patient is a 69-year-old man who has had uncomplicated cataract extraction with
lens implant of the left
eye and maintains good vision. He is bothered by quite poor vision in the right
eye from a cataract and
enters for similar procedure in the right eye. He has had no other eye diseases in
the past.
SOCIAL AND FAMILY HISTORY

He is married and is self-employed in an auto wrecking firm. He smokes cigarettes.
PAST HISTORY
Has been in good general health and takes no medicine routinely. Had a fracture of
the right ankle in the
past and no other surgical procedures. He is being treated for an allergy of the
skin.
ALLERGIES1
He has no known drug allergies.
REVIEW OF SYSTEMS
Review of systems reveals a negative history of unusual bleeding or bruising. No
reaction to anesthetics.
Cardiopulmonary: No history of shortness of breath, asthma, or angina.
Gastrointestinal: Normal bowel habits.
Genitourinary: Occasional nocturia.
PHYSICAL FINDINGS
VITAL SIGNS:2 Blood pressure 160/90. Pulse 68 and regular.
EYES: Recent eye examination showed best vision of 20/100 in the right eye and
20/25 in the left. Pupils
and extraocular motility and visual fields by confrontation were3 normal.
Intraocular pressures were 16.
Slit-lamp exam showed blepharitis in each eye, with normal corneas and a dense
posterior subcapsular
cataract in the right eye. The left eye had a normal pseudophakia. Dilated fundus
examination in each eye
was normal.
EARS, NOSE AND THROAT: There was cerumen in the external canals. The oral cavity
showed teeth in
good repair, and the pharynx had no lesions.
NECK: Neck had normal carotids without bruits.
CHEST: Chest was clear to auscultation.
HEART: Heart had a regular sinus rhythm without murmur.
DIAGNOSIS
1. Cataract of the right eye.

2. Pseudophakia of the left eye.
PLAN
Cataract extraction with lens implant of the right eye under local anesthetic as
an outpatient. He
understands the major risks such as loss of the eye and that an implant may not be
done because of
surgical problems.
2058 characters
1 New paragraphs are added to separate sections of the report appropriately.

3 Edit are to were for proper tense.

HEENT DICTATION #16
DIAGNOSIS
Uncontrolled glaucoma.
OPERATION
Trabeculectomy of the left eye.
HISTORY
This man has been under treatment for his glaucoma for a long period of time. He
has had a partial central
retinal artery occlusion in the left eye several years ago and had developed a
proliferative retinopathy.
This had been treated with laser. He now developed a glaucoma unresponsive to any
medication.
HOSPITAL COURSE1
The patient was taken to the operating room. Postoperatively he had no difficulty
with his eye, and this
procedure went on to the expected good outcome.
580 characters

HEMATOLOGY/ONCOLOGY/IMMUNOLOGY DICTATION #1
OFFICE NOTE (1:00)
This patient initially underwent an attempted left axillary debulking along with
removal of about 15
subcutaneous metastases scattered around his body 3-1/2 weeks ago. We abandoned
the axillary tumor
removal because of the need for extensive muscle and perhaps scapular resection to
accomplish adequate
debulking, and the patient had not really been prepared for that. Since that time,
however, the lesion has
grown a little bit. It is now slightly larger than a large grapefruit and is
beginning to ulcerate through the
skin. It appears that we may be able to save the arm but need to resect perhaps
the lower half of the
scapula.
DIAGNOSIS
Bulky metastatic melanoma of left axilla.
701 characters

The patient is a 69-year-old female who has a history of human immunodeficiency

virus (HIV)1 and
Mycobacterium avium complex (MAC).2 She has mesenteric and retroperitoneal
lymphadenopathy that
has been followed by serial CT scans. Her lymphadenopathy is progressing, and she
therefore is referred
for a biopsy to evaluate for possible recurrent MAC or lymphoma.
386 characters


This patient underwent extensive debulking of recurrent intra-abdominal

liposarcomas about 3 weeks ago.
Initially his problem was mainly failure to thrive. Over the last couple of days,
however, the left lower
quadrant drains that had been placed at the time of surgery have started putting
out what appears to be
enteric content (later confirmed by barium), and the patient has been spiking
fevers, suggesting an abscess
that has not adequately drained. We felt that, if possible, reentering the abdomen
in the midline and
exploring the left upper quadrant from that approach would be perhaps more
satisfactory, at the same time
carrying out a proximal diverting colostomy.
698 characters

CHIEF COMPLAINT
Prostate cancer.
This is a1 75-year-old man who was found to have localized adenocarcinoma of the
prostate following
evaluation for an elevated PSA2 of 7.6 ng/mL. He underwent transrectal ultrasound
and biopsies which
demonstrated an adenocarcinoma, Gleason score 5 (2+3), clinical stage T2b. The
patient had a cancer
consultation at that time and selected androgen ablation as his treatment of
choice. He was begun on
androgen ablation, and he ultimately had a PSA nadir of less than 1.3 He remained
on androgen ablation
for several years before developing disabling symptoms secondary to the androgen
ablation. This
included hot flashes, muscle weakness, lethargy, and weight gain. For the past
several years, he has been
on a program of intermittent androgen ablation with his PSA reaching as high as
18.65 before
reintroduction of the medication. In spite of infrequent use, the patient could
not tolerate the androgen
ablation side effects. In October I saw the patient for the first time and noted
that his PSA was 10.4. His
digital rectal examination revealed a broad, flat, firm prostate gland without
raised nodules. The patient
was advised to consider reintroduction of androgen ablation but returned 2 months
later, at which time his
PSA had risen to 15.2 and told me that he was unwilling to have any further
androgen ablation. In January
he underwent a bone scan and abdominal and pelvic CAT scan for restaging. All of
the staging
demonstrated no evidence of metastases.
I met with the patient and his wife again in January, at which time we discussed
cryosurgical ablation of
the prostate. He was fully informed of side effects, risks, and complications
which included impotency
following the cryosurgery. He understood the risks and was now scheduled for
cryosurgical ablation of
the prostate. Approximately 1 week ago, he was found to have a urinary tract
infection and was found to
have enterococcus. He was originally treated with quinolones and then switched to
ampicillin.
Throughout the bacteriuria and pyuria, he has been asymptomatic. He has been on
Flomax for urinary
outlet obstructive symptoms, and on 0.4 of Flomax, his ultrasound postvoid
residual is 39 mL.1
PAST HISTORY
Prior Surgery: Tonsillectomy.
Medical Illnesses: History of atrial fibrillation which began approximately 6
years ago and is well
controlled on amiodarone 200 mg per day.
Allergies: Drug allergies denied.
Social History: No history of smoking or alcohol.

(milliliters).

FAMILY HISTORY
Wife living and well. Two children living and well. No family history of prostate
cancer.
REVIEW OF SYSTEMS
HEENT: Not remarkable.
Respiratory: Pneumonia in the distant past without sequelae. Nonsmoker. No history
of asthma or
hemoptysis.
Heart: Atrial fibrillation. No history of angina, myocardial infarction (MI),4
congestive heart failure
(CHF),5 or arrhythmia.
Gastrointestinal:6 Not remarkable.
Genitourinary:7 Potent. Sexually active. Recent history of urinary outlet
obstructive symptoms, and a
recent history of a urinary tract infection responding to alpha blockers and
antibiotics.
Neuromuscular: Not remarkable.
Hematopoietic: No history of bleeding disorders.
GENERAL:8 Physical examination revealed a well-nourished, well-developed 75-year-
old man who
appeared younger than his stated age.
HEENT: Normal.
CHEST: Normal AP diameter.
LUNGS: Clear breath sounds bilaterally.
HEART: Regular rhythm. No evidence of murmur or arrhythmia.
ABDOMEN: Soft. Active bowel sounds. No evidence of liver or spleen enlargement. No
evidence of
inguinal hernia.
GENITALIA: Penis circumcised. Urethral meatus adequate. Testicles normal size,
shape, and
consistency.
RECTAL: Digital rectal examination revealed a 28-g, firm, flat, symmetrical
prostate gland without
raised nodules. No abnormal rectal masses.
EXTREMITIES: Normal.
IMPRESSION9
1. Adenocarcinoma of the prostate, Gleason score of 5, clinical stage T2b.

2. Unable to tolerate androgen ablation.
3. Atrial fibrillation.
PLAN
Cystoscopy. Cryosurgical ablation of the prostate.
4048 characters

Add This is a to avoid starting the sentence with a numeral.
The abbreviation for a common lab test does not need to be expanded.
Do not use the less than symbol (<1).
Expand an abbreviation on its first use and place the abbreviation itself within
parentheses.
parentheses.
Expand abbreviations used in headings.
Expand abbreviations used in headings.
Add headings for consistency in format.
Numbers are added to the diagnosis or impression when there is more than one item.

ADMITTING DIAGNOSIS
Chronic fatigue syndrome.

The patient is a 33-year-old white female with a history of chronic Epstein-Barr
virus syndrome. Patient
also diagnosed with IgG subclass immunodeficiency. She is admitted today for a 6th
course of gamma
globulin therapy. She continues to complain of fatigue which is unchanged since
last admission but has
markedly improved in the last 4-6 months. She is receiving p.o. amoxicillin at
this time for an upper
respiratory tract infection which she describes as being a sore throat, postnasal
drainage, and cough with
occasional headache. She denies any fever, chills, or sweats. Tolerated the last
infusion well except for
some headache. Glaucoma diagnosed 2 weeks ago.
LABORATORY DATA
EBV panel and IgG levels are pending.
HOSPITAL COURSE
Patient was admitted for her 6th dose of IV Gammagard therapy. The patient
received 15 g of intravenous
gamma globulin over a period of 4-5 hours. Patient tolerated it without any
difficulty. No change in vital
signs. She did not complain of any shortness of breath, headache, or lower back
pain. Patient was
concerned about the diagnosis of glaucoma which she had just been recently
diagnosed with. Discharged
to home in good condition.
PRINCIPAL DIAGNOSIS
Chronic fatigue syndrome.
SECONDARY DIAGNOSIS
IgG subclass deficiency.
1360 characters

DISCHARGE DIAGNOSES
1. Recurrent colon carcinoma with small-bowel obstruction.

2. Dehydration and1 malnutrition secondary to above.
3. Hepatic failure.
4. Acute pancreatitis.
PROCEDURES
Gastrojejunostomy, tube gastrostomy.
HISTORY
This was a 68-year-old black female with colon carcinoma, with a left upper
quadrant mass and partial
small-bowel obstruction, which regressed on 5-FU and leucovorin chemotherapy. The
patient was
admitted at this time complaining of 2 weeks of gradually worsening weakness,
nausea, and vomiting,
and unable to eat for several days.
Physical examination on admission revealed a dehydrated, weak black female
appearing about her stated
age. There was no lymphadenopathy. Her lungs were clear. Cardiac3 exam was benign.
Abdominal exam
revealed a left upper quadrant mass palpable that was tender. Bowel sounds were
unremarkable. There
was no clubbing, cyanosis, or edema. Skin turgor was poor.
LABORATORY DATA
BUN was 79, creatinine 1.9, sodium 125, potassium 3.3, white count 7600,
hematocrit 41.7, and platelets
229,000 on arrival.
HOSPITAL COURSE
The patient was started on nasogastric (NG)4 suction and hyperalimentation. She
was taken to surgery at
which time a bypassing gastrojejunostomy and tube gastrostomy were5 performed.
Extensive tumor was
found filling the base of the mesentery and obstructing the duodenum. There was no
sign of obstruction
beyond this. The surgery was complicated by a small subcutaneous abscess which was
successfully
drained. Unfortunately it was never possible to completely remove her NG tube,
despite the surgery. An
upper GI revealed no obstruction or delayed emptying, yet she persisted in having
significant nausea and
vomiting when the tube was clamped or removed. At that time it became evident that
other problems were
present, and acute pancreatitis was discovered with an amylase and lipase that
were significantly elevated.
NG suction was continued along with appropriate hydration support. Despite this
support the patient�s
condition continued to deteriorate. It was never possible to remove her NG tube.
She then developed
progressive hepatic failure with a bilirubin of 11.3. She was started on morphine
infusional therapy for

treating constant upper abdominal pain. Her hepatic dysfunction continued to
worsen, and she became
progressively more and more obtunded. She finally expired at 2320. An autopsy was
not obtained.
CAUSE OF DEATH
Cause of death was felt to be her progressive carcinoma.
2487 characters
1 The article and

was added because dehydration and malnutrition are two separate items.
3 Edit the dictated coronary to cardiac for accuracy.
5 Edit was to were for subject-verb agreement (compound subject).

A very pleasant 87-year-old white man admitted for an observation short stay for
severe symptomatic
anemia (hemoglobin and hematocrit, 5.7 and 17.3),1 for the purpose of transfusion
of packed red blood
cells.
Please see patient�s old medical records for details of the patient�s past medical
history which is well
documented in the old medical records.
In any case the patient did receive 6 units of packed red blood cells during this
hospitalization,
hemoglobin and hematocrit increasing to 12.2 and 35.1,2 with clinical improvement,
and the patient was
discharged the following morning to follow up with me in my office.
646 characters
1 Alternative: hemoglobin 5.7, hematocrit 17.3.

2 Alternative: hemoglobin 12.2, hematocrit 35.1.

CONSULTATION (2:00)
This patient was seen by me with complaints of feeling unusually tired for about 2
months, of being
unable to concentrate, and of having a swollen cervical gland. She denied
headaches, vertigo, anorexia,
bowel irregularities, abdominal pain, skin rash, menstrual irregularities, sore
throat, cough, rhinitis, or
insomnia. She had been napping a lot in the 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 otherwise. There is no family history of diabetes. Her father died
of bleeding esophageal
varices. She had some 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 diagnosed
as an acute viral
infection or �flu.�
On examination she had a temperature of 97.4, pulse 92, blood pressure 116/70. She
was obviously
depressed and a little lethargic but cooperative and mentally clear. Pupils were
equal and reactive. Fundi
normal. ENT unremarkable. One or two small anterior cervical nodes palpable and
slightly tender.
Hearing normal bilaterally. Breasts normal. Lungs clear. Heart regular without
murmurs, clicks, or rubs.
Abdomen soft, scaphoid, nontender, without masses. Extremities normal. Deep tendon
reflexes normal,
bilaterally equal. Romberg was negative.
The patient was advised that she probably had no organic illness but that
laboratory studies would be
done. To our surprise she showed a 50% lymphocyte count (6 atypical) on her
differential and a positive
mono test.1 The heterophile was weakly positive at 1:56. Total white count was
9762. Urinalysis and
chemistry profile were negative.
When I saw the patient today, I told her that the laboratory studies are
compatible with either
an incipient case of mononucleosis or one that is just wearing down. In the light
of her history,
the latter is surely more likely. I told her mother this, too. Already today the
patient looks more
chipper and alert and in better spirits, even though I gave her no medicine.
2117 characters
1 The generic form is used if it is not known if the trademarked Mono-Test was
ordered.

This 81-year-old white female has had several hospitalizations for mesothelioma of
the peritoneal cavity
as well as the thoracic cavity. On this admission she presented with persistent
nausea and vomiting, vague
abdominal pain, and marked anxiety.
Physical examination showed the presence of a Groshong catheter in the right

subclavian area. A large
abdominal mass was palpable. This is a chronic situation. She had chills and fever
and was seen in
consultation and felt that additional surgery was not in order unless the
gastrostomy tube was a problem.
Nutritional support team was called in and was1 a great help in maintaining proper
nutrition. There was a
mild anemia present, but considering her chronic debility, this was truly not
remarkable. Patient had
difficulty handling any oral intake initially. Even small amounts of liquid
resulted in emesis.2 She was
given Demerol for abdominal pain, and repeated attempts were made to give her
small amounts of oral
support. She was begun on Rocephin 1 g b.i.d. There was particular attention paid
to her electrolytes.
Blood cultures were done which showed no pathogen. She was begun on clear liquids.
Temperature
persisted. She was able to retain some oral nutrition in small amounts, had a
lessening of her abdominal
discomfort; the temperature, however, persisted. I believe that the febrile
situation is not particularly
infective in origin but probably related to her neoplastic process and that
further antibiotics would be to
little avail. She had improved sufficiently where I felt she could be discharged
to be followed as an
outpatient. Additional studies included an abdominal series with no particular
clinical yield. The CT
showed 2 large cystic-like structures within the abdomen. These are described in
detail in the report. Also
chronic pancreatitis and cholelithiasis and small left pleural effusion were seen.
Iron-binding capacity was
167 with the ferritin of 610. Multiple electrolytes were ordered as well as BUN,
and appropriate
supplementation was afforded IV or by the nutritional team. Patient is discharged
to be seen as an
outpatient.
FINAL DIAGNOSIS
1. Mesothelioma of abdominal and thoracic cavities.

2. Fever, probably secondary to the mesothelioma.
3. Intermittent incomplete bowel obstruction.
PROGNOSIS
Prognosis is poor.
2324 characters
1 Edit were to was for subject-verb agreement (�team . . . was�).

2 Alternative: Patient had difficulty handling any oral intake initially; even
small amounts of liquid resulted in
emesis.
3 Number diagnoses when more than one is given.
4 Edit the dictated cavity to plural cavities.

DIAGNOSIS
Locally advanced pancreatic cancer.

The patient reports a 1-year history of vague abdominal discomfort and
constipation. He then developed
some pain in the lower abdomen. Abdominal CT scan revealed gallstones and a mass
at the head of the
pancreas. Endoscopic retrograde cholangiopancreatography (ERCP)1 was performed
with cytologic
brushing at that time, which showed stricture of the common bile duct with stent
placement as well as
sphincterotomy. The patient was evaluated by Surgery, who believed the portal vein
was involved with
the tumor and was unresectable.2 He then was referred for consideration of
systemic therapy. A
percutaneous needle aspirate of his pancreatic mass was consistent with pancreatic
primary. He received
gemcitabine. He reports today to receive his 4th dose.
REVIEW OF SYSTEMS
The patient tolerates his chemotherapy very well without any significant side
effects. His only complaint
is of occasional shoulder pain which begins in the right and radiates to the left
shoulder. This is alleviated
with Advil and occurs on an approximately once-a-week basis. Another complaint is
of frequent hiccups
which occur after he has eaten. He has no further pruritus since the stent was
placed to alleviate his
jaundice. Otherwise the patient has no severe complaints. He denies headaches,
mouth sores, dysphagia,
dyspepsia, nausea, vomiting, constipation, diarrhea, dysuria, shortness of breath,
cough, chest pain,
palpitations, bruising, bleeding, pruritus, or bone pain.
MEDICATIONS
Megace 10 mL b.i.d., Covera 360 mg at bedtime.3 Arthrotec 75 mg q.a.m.,
hydrochlorothiazide (HCTZ)
one-half tab daily.4 Cardura, 6 in the morning and 2 in the evening. Advil as
needed. Vitamin, mineral,
and herbal supplements.
ALLERGIES
Sulfa results in a rash, and aspirin has caused bleeding ulcers in the past.
LABORATORY DATA
Specimens drawn today reveal a white blood cell count of 5100, hemoglobin 9.7,
hematocrit 29.8, and
platelet count 323,000. Chemistries were not obtained today.

GENERAL:6 A pleasant gentleman who is in no acute distress. His weight is down a
few pounds to 197.1.
VITAL SIGNS: Blood pressure 157/70, heart rate 74, respirations 18.
HEENT: Pupils equal, round, and reactive to light. Extraocular movements were
intact. Sclerae were
mildly icteric without injection. The oropharynx was unremarkable without evidence
of thrush or lesions.
There was no cervical, supraclavicular, axillary, or inguinal lymphadenopathy.
CARDIOVASCULAR: S1, S2. 7 Regular rate and rhythm.
RESPIRATORY: Lungs were clear to auscultation bilaterally.
ABDOMEN: Abdomen was soft, with tenderness in the right upper quadrant to deep
palpation, liver edge
approximately 4-5 cm below the right costal8 margin. Bowel sounds were hypoactive.
Otherwise no
splenomegaly or masses.
EXTREMITIES: Extremities revealed no edema or cyanosis. There was no tenderness to
palpation of the
vertebral column or the kidneys. There were no focal neurologic deficits.
ASSESSMENT AND PLAN

He will receive his 4th of 7 weekly doses of gemcitabine at 1000 mg/m2. 9 With the
above he was given a
prescription refill for Megace. He will return in 1 week to resume therapy.
3230 characters
parentheses.
2 Edit the dictated �nonresectable� to the correct term unresectable.
3 The dictated �h.s.� is on the dangerous abbreviations list and should be
replaced with at bedtime.
4 Edit the dictated �q.d.� to daily to avoid using an abbreviation on the
dangerous abbreviations list.
8 Edit the incorrectly dictated �chondral� to the correct term, costal.
9 Alternative: 1000 mg per meter squared.


This 70-year-old man is admitted for an open lung biopsy. This man, who has a
long-standing history of
heavy smoking (more than a pack a day since the age of 12), was recently found to
have multiple bilateral
pulmonary nodes, in all likelihood malignant. Bronchoscopy and transbronchial lung
biopsies failed to
produce a tissue diagnosis. Tomorrow,1 the patient will undergo an open lung
biopsy through a small
thoracic incision, so that, if the malignant nature of his illness is confirmed,
as is almost certain, palliative
treatment can be administered based on the specific type of tumor.

The patient had a right inguinal hernia repair some 20 years ago. At about the
same time, the patient also
had his left testicle removed. He cannot tell me whether the lesion was benign or
malignant, but the
interval between removal of that lesion and the development of his present problem
is so long that any
connection seems extremely unlikely.
ALLERGIES
The patient gives history of allergy to penicillin.
MEDICATIONS
He currently takes Zantac twice daily.
SOCIAL HISTORY
The patient also describes suffering from alcoholism in the past. His alcohol
consumption now is limited
to a couple of beers a day.
GENERAL: On physical examination the patient is a 70-year-old man who is quite
thin. He is mentally
very well preserved.
HEENT: The head is normal. The pupils are equal in size, round, and reactive.
NECK: The neck is supple.

CHEST: Typical changes of severe chronic emphysema. Diminished breath sounds
bilaterally. Bilateral
wheezes.
HEART: The heart is regular with no prominent murmurs.
ABDOMEN: The abdomen is nondistended and soft.
RECTAL: Rectal examination deferred.
EXTREMITIES: Unremarkable.
NEUROLOGIC: Neurologic examination, no gross deficit.
IMPRESSION
Probable primary bronchogenic carcinoma with bilateral dissemination.
PLAN
Open lung biopsy tomorrow.
1963 characters
1 On the job, you would change tomorrow to a date. When referring to a day in a
report, use the day�s name and the
date. Avoid terms such as last Monday or next Wednesday.

OFFICE NOTE (1:00)
A 75-year-old man with a long history of known petroclival cerebellopontine angle

presumed
meningioma, diagnosed by neuroimaging many years ago during initial workup, and
new-onset
trigeminal neuralgia. This lesion has been followed conservatively by an outlying
neurosurgeon and
found to be progressively growing, and patient has also developed signs and
symptoms of a
neurodegenerative disorder, possibly consistent with parkinsonism, although with
some cerebellar and
extrapyramidal motor symptoms along with it. After careful consideration of
treatment options, including
continuing observation, radiation therapy, stereotactic radiosurgery, the decision
was made to proceed
with stereotactic radiosurgery, recognizing the fact that the lesion had already
grown to abut against the
surface of the brain stem and certainly did carry some toxicity risk from
treatment for his posterior fossa
cranial nerves and his underlying pyramidal tract.
963 characters

PROVISIONAL DIAGNOSIS
1. Acquired immunodeficiency syndrome (AIDS).1

2. Monilial esophagitis.
3. Rule out pneumocystis pneumonia.
DISCHARGE DIAGNOSIS
1. Acquired immunodeficiency syndrome (AIDS).

2. Monilial esophagitis, resolved.
3. Probable pneumocystis pneumonia.
Patient is a 35-year-old white male who presented in my office for the first time
with a complaint of
dysphagia and food sticking. He had stated this had been going on for 6 weeks with
food sticking all the
way from the back of the throat intermittently down to the lower esophageal area
accompanied by pain.
He has also had vomiting of blood. He had a barium swallow and was told it was
abnormal and that he
probably had a tumor. He did not follow up on this. He went to the emergency room
and was told he had
thrush and was treated with Mycostatin oral suspension with some relief. When he
presented in my office,
he continued to have low-grade fever, dysphagia, and on examination was noted to
have thrush. He
complained of some slight shortness of breath. A chest x-ray was done in the
office which was normal. A
barium swallow as an outpatient that day revealed monilial esophagitis but no
evidence of any tumor. His
white count in the office was 3400. He was started on Mycelex troches, and HIV2
and T cells were drawn.
HIV was positive, confirmed by Western blot. The T-cell studies showed a severe
decrease in T4 to 93,
normal being over 400. His T4/T8 ratio was 0.06. At that point patient was advised
to start on zidovudine
(AZT)3 and aerosolized pentamidine prophylaxis, but he started having some
increasing shortness of
breath, so a gallium scan was scheduled as an outpatient to evaluate for further
Pneumocystis carinii
pneumonia (PCP)4 in view of the normal chest x-ray, but he was admitted because of
increasing
symptoms. 5 An RPR in the office was nonreactive.
On physical examination he was alert and oriented, in no acute distress. Blood

pressure 120/90, weight
156, height 5 feet 11 inches,6 temperature 99. Chest reveals some rhonchi. Heart:
Normal sinus rhythm.
Abdomen: No hepatosplenomegaly. Skin: No evidence of Kaposi sarcoma (KS)7 lesions.
Patient was seen also in consultation. A gallium scan was done which showed
diffuse uptake in the lungs
consistent with an infectious process or possibly PCP. A bronchoscopy with
washings, biopsies, etc., was
done for PCP stains, acid-fast, cultures, and cytologies. All of this was negative
including sputums for
pneumocystis. Chest x-rays remained normal, but patient did have a lot of chest
congestion, although he
is a smoker. Obtained further workup with CMV titers, serum cryptococcal antigen,
and blood cultures.

These were all negative. The patient because of headache toward the end of his
hospitalization had a
spinal tap. This again was normal with normal proteins and no evidence of
cryptococcal infection.
Patient was improved on discharge. He was treated with erythromycin and

empirically with aerosolized
pentamidine 600 mg per day for 2 weeks. He is to continue this after discharge, to
follow up with a full 2
weeks of treatment, and after that to start on zidovudine (AZT) and pentamidine8
prophylaxis.
Blood gases on room air were pH 7.37, pCO2 45, pO2 75.9 Platelet count was
256,000, and white count
was 3400.
The patient, toward the end of his hospitalizations, had persistent epigastric
pain and nausea and
vomiting, so an endoscopy was done. The physician10 did not see any evidence of
further monilial
esophagitis, which has cleared with the Mycelex and some Nizoral, but he did see a
slight duodenitis, so
he did start him on Reglan and Zantac. Patient continued on this as an outpatient
after discharge.
EKG was normal. Again CMV and cryptococcal antigen screens were both negative. Pro
time11 and PTT
were normal. Cardiac enzymes were negative (because the patient was having chest
discomfort at one
point).
In summary this patient presented with monilial esophagitis, some shortness of

breath, positive HIV, and
very depressed T cells. He had negative studies for pneumocystis, cryptococcus,
acid-fast bacterial
infections. He had epigastric pain which, on endoscopy, the etiology was not
certain, possibly some slight
duodenitis. The monilial esophagitis was certainly cleared at that point as well
as the thrush. He is to
finish up on the aerosolized pentamidine 600, to finish a 2-week course daily;
this is arranged, and then to
start on zidovudine (AZT). He will be followed up in the office with serial counts
and aerosolized
pentamidine12 every 2 weeks at 150 mg prophylaxis. PCP is presumptive based on
gallium findings,
symptoms, and HIV and T-cell status. His chest x-ray was normal, and his blood
gases were normal.
Clinical findings did show some shortness of breath, though, and cough and
rhonchi. He will also
continue on Zantac and possibly Carafate as an outpatient for the epigastric
discomfort.
4873 characters
1 Expand abbreviations used in diagnoses.

2 HIV does not need to be expanded here because it is being used as a brief name
for an HIV test and not the disease
condition.
3 AZT has undergone a name change to zidovudine; dictators, however, have chosen
to stick with the more easily
pronounced name.
parentheses.
5 This very long sentence could be divided into two sentences.
parentheses.
9 Alternative: PCO2, PO2.
10 The dictated �he� (the patient) is edited to �the physician� or �the
endoscopist,� who performed the endoscopy.
11 Prothrombin time is preferred, but pro time and PT are commonly used in
dictation of laboratory data.

BRIEF HISTORY AND PHYSICAL FINDINGS

This 85-year-old white married male with a long history of insulin-dependent
diabetes mellitus had been
having more trouble getting out of bed, decreased appetite with nausea and
vomiting, diarrhea, and
inability to keep fluids down. Was admitted with hypovolemia, nausea, vomiting,
and diarrhea.
Physical findings revealed that he is essentially blind. Wasting of musculature in

general that is mild to
moderate. Edentulous. Endarterectomy1 scar on the right. Slightly hyperactive
bowel sounds. Hemoccultnegative
stool.
SIGNIFICANT LABORATORY DATA

Free T4 was less than 0.3, with normal 0.7 to 2.9.2 Free T3 was 0.56, with normals
of 3.37 to 7.05.
Leukocyte alkaline phosphatase slightly elevated to 104; normal is up to 95. Total
T4 was 7.5. TSH3 of
74.4; normal is up to 4.6. Hemoglobin A1C was 4.8, with normals 3.4 to 6.2.
Glucose on admission was
only 70. BUN 1.9, creatinine 36.3. Uric acid of 8.8, and cholesterol of 390.
Sodium was slightly
decreased at 133. Potassium normal at 4.6. LDH elevated, 917. Urine culture was
negative. Serum
lysozyme was 8.9, with normals 2.8 to 8.0. Blood culture was negative x2. Serial
electrolytes, BUN,
creatinine were followed until they normalized. Dilantin level was obtained; it
was less than 2.5,
confirming that he had been off his Dilantin for some time. CBC was followed in
serial fashion showing
an initial white count of 20,700, gradually falling to 16,300, with the hemoglobin
dropping from 10.2 to
9.8 as he became hydrated, MCV remaining at 106-107. Differential profile looked

quite abnormal with
many immature forms, myelocytes, metamyelocytes, promyelocytes, and blasts, with
some nucleated
RBCs and basophilic stippling 1+.
Bone marrow biopsy was obtained showing basically hypoplasia and myelofibrosis,
with the comment
showing that there is no evidence of leukemia at the present time. The bone marrow
showed hypoplasia
even in the areas not involved in the process of myelofibrosis, which was in
contrast to the previous bone
marrow and which showed increased hematopoiesis in the other areas.
Chest x-ray showed mild cardiomegaly and scarring in the left lung base. A repeat
chest showed what
appeared to be free intraperitoneal air beneath the right hemidiaphragm, possible
new left lower lobe
atelectatic infiltrate. Abdominal view later showed a loop of colon interposed
between the liver and the
right hemidiaphragm with no definite free air seen. Repeat x-ray showed no
pneumoperitoneum and
better left lobe aeration. EKG showed rather prolonged PR interval of
approximately 0.28,4 overall
impression of low voltage, nonspecific T-wave changes, suggested to rule out a
hypothyroid state because
of the low voltage.

COURSE IN THE HOSPITAL
The patient was admitted, placed on rainbow coverage, intravenous fluids to
rehydrate him, Imodium to
control loose stools, continued on his dipyramidole5 and Trental, all of the above
tests ordered. He
generally had more problems with hypoglycemia than hyperglycemia, and we had to
continually decrease
his insulin dosages. He was begun on Cefobid because of the possible pneumonia at
1 g b.i.d., and he was
improving enough. Social Service was requested to talk with patient and family
regarding more help at
home. Call my office in about 2 weeks for the results of the rest of his tests.
Home Health is to do a home
evaluation.
The prognosis is fair on the short term, very poor on the long term because of the
bone marrow disease.
3497 characters
1 The dictated �with� is deleted before endarterectomy and a new clipped sentence
begun.
2 Do not use a hyphen to indicate range if decimals and/or commas appear in the
numeric values.
3 The dictator erroneously says �THS.�
4 The dictator says �point two eight.� Add a zero before the decimal for values
under 1.
5 The dictated dipyramidole
is the Canadian version. The correct U.S. drug name is dipyridamole (Persantine).

ADMITTING DIAGNOSIS
Probable acute lymphoblastic lymphoma (ALL).1

He is a 28-year-old white male with a history of lymphoblastic malignant lymphoma
of his anterior
mediastinum, treated with chemotherapy CHOP (cyclophosphamide, hydroxydaunomycin,
Oncovin,
prednisone) and postchemotherapy2 radiation for a total of 2520 rads divided in 14
fractions to his
anterior mediastinum. He developed right-sided chest pain and was3 noted to have
an increasing white
blood count with premature component, thus was transferred for aggressive
chemotherapy.
The patient developed right-sided chest pain on and off for several weeks, but it
became constant and
increased in severity approximately 4 days prior to admission. He contacted the
hospital radiation
department and was begun on Trilisate and Tylox for presumed cartilage
inflammation. The pain
continued to increase, so he went to the emergency room, where he was noted to
have a leukocytosis with
a white blood count of 39,600.4 He was admitted for evaluation, and his white
blood count increased to
49,100 with a differential of 16 segs, 7 bands, 3 lymphs, 13 atypical lymphocytes,
2 monocytes, 2
eosinophils, 4 metacytes,5 4 myelocytes, 1 promyelocyte, and 48 blast cells. His
leukocyte alkaline
phosphatase (LAP)6 was 105. CSF was normal with a glucose of 70 mg/dL and a
protein of 34 mg/dL and
no cells. CT scan showed no adenopathy or chest wall abscess. Chem profile was
normal with the
exception of an ASTRA7 at 62 and an LDH of 330. Bone marrow aspiration and biopsy
revealed ALL.

Lymphoblastic malignant lymphoma diagnosed with an anterior mediastinal biopsy. He
was given 6
courses of chemotherapy (CHOP) every 3 weeks.9 His Adriamycin total dose was 600
mg. He also
received postchemotherapy radiation with 14 treatments to the chest for a total of
2520 rads. Symptoms
upon diagnosis included night sweats and midline chest pain that felt like
indigestion.
MEDICATIONS ON ADMISSION
Medication10 upon admission was Antivert 25 mg p.r.n.
ALLERGIES
Allergies include codeine which causes nausea, penicillin which causes him to pass
out, and oxycodone11
which causes him to become light-headed.
SOCIAL HISTORY
He is married with 3 children with ages of 4 to 11. He works in communications,
and he does not smoke
or drink.

FAMILY HISTORY
His mother is alive with hypertension and palpitations. His father is dead at age
69 of a myocardial
infarction (MI)12 and Alzheimer�s13 disease. He has a positive family history for
cancer including lymph
node and lung cancer in uncles, colon cancer in a cousin, and a genitourinary
(GU)14 cancer in an aunt. He
denies a family history of diabetes, tuberculosis, or chronic obstructive
pulmonary disease (COPD).15
REVIEW OF SYSTEMS16
Nausea for several years. He has tried Reglan and Tigan without relief. Occasional
migraine headaches.
GENERAL:17 This is a well-nourished, well-developed white male in no apparent
distress.
VITAL SIGNS: Afebrile, with a pulse of 84, respirations 24, blood pressure 118/80.
HEENT:18 Normocephalic, atraumatic. Pupils equal, round, reactive to light

(PERRL). Extraocular
movements intact (EOMI). Fundi benign. Right tympanic membrane (TM) clear, left TM
occluded. Nose
without drainage. Mouth pink and moist without lesions, exudate, or petechiae.
NECK: Supple without adenopathy.
CHEST: Clear to auscultation with no axillary19 lymphadenopathy. No tenderness in
the right
inframammary region. A well-healed approximately 4-cm scar of the left chest20 and
a Groshong catheter
in his right chest.
HEART: Heart has regular rate and rhythm without murmur, S3, S4.
BREASTS: Breasts are without gynecomastia21 or masses.
BACK: No costovertebral angle (CVA)22 or spinal tenderness.
ABDOMEN: Soft, nontender. Spleen and liver not palpable. Liver span is
approximately 6-7 cm, and
bowel sounds are normoactive.
GENITALIA: Circumcised male with descended testes, nontender, and without masses.
RECTAL: Rectal exam reveals a smooth prostate, heme-negative stool, and normal
sphincter tone.
PULSES: Pulses are 2+/4 in the dorsalis pedis, posterior tibial, and radial
arteries.
NEUROLOGIC: Cerebellar function is grossly intact. Cranial nerves 2-12 are grossly
intact.
EXTREMITIES: He has good range of motion in all extremities, and gait is normal.
LABORATORY DATA
White blood count 58,700,23 hemoglobin 15.6, hematocrit 47.5. Platelets 187,000.24
MCV 92. Sodium
141, potassium 4.0, chloride 105, CO2 23. BUN 15, creatinine 1.0, and glucose 95.
Calcium 10.0,
phosphate 3.6, uric acid 6.2, total protein 7.7, albumin 4.3, total bilirubin25
0.8, alkaline phosphatase26 96,
AST 54, LDH 1225, cholesterol 312.
HOSPITAL COURSE
The patient was admitted and bone marrow biopsy taken, which revealed acute
lymphoblastic leukemia.
He was begun on the L10 protocol with mass measured at 2.12 m2.27 He was given the
L10 protocol,
which involved vincristine 4 mg every Thursday for28 5 weeks, prednisone 40 mg
t.i.d. for 36 days, and
intrathecal methotrexate 12 mg. MUGA scan revealed an ejection fraction of 71%.
Lumbar puncture
(LP)29 showed clear fluid with a glucose of 88, protein of 43, 264 RBCs, 1 WBC, a
small mono in tube
#1. The patient was discharged on day 6 of his L10 protocol, to return to clinic
on Thursday for his
second dose of 12 mg methotrexate given intrathecally and vincristine 4 mg IV. He
will return to the
hospital to be readmitted in order to have a Hickman placement on Wednesday prior
to receiving his next
round of methotrexate, vincristine, and Adriamycin.30

5513 characters
1 Expand abbreviations used in the diagnosis.

3 Insert was to complete the verb.
4 Alternative: 39.6 thousand. Use 39,600 for consistency with other white count
values; otherwise, it is acceptable to
transcribe 39.6 thousand if dictated.
Flag this term to the dictator�s attention for correction. There is no cell
called metacyte.
6 Expand uncommon abbreviations not readily recognized.
7 ASTRA is a combination of tests much like a chemistry panel. The dictator
probably means AST. This should be
flagged to the dictator�s attention for correction.
8 Ignore the dictated semicolon.
9 The patient had 6 courses of CHOP at 3-week intervals.
Use the singular form since only one is given, and change the verb to was.
11 The dictator erroneously says �oxycodeine.�
12 Expand an abbreviation on its first use and place the abbreviation itself
within parentheses. Change the article to a
before a consonant sound.
within parentheses.
parentheses.
16 Edit the dictated heading �review of symptoms� to a standard heading.
18 Throughout the paragraph, expand abbreviations on first use and place
abbreviations within parentheses. Edit
punctuation appropriately. Edit to periods the multiple semicolons dictated
throughout the paragraph.
19 The dictated axilla lymphadenopathy is edited to the expected term axillary
lymphadenopathy.
Omit dictated period.

21 The dictator erroneously says gynecomastica. Edit to gynecomastia.
within parentheses.
24 Alternative: 187 thousand.
Expand unacceptable brief forms.

27 Alternative: 2.12 meters squared.
28 Use for rather than times or the symbol x when the word times is dictated and
can be translated as for.
within parentheses.
No discharge diagnosis is given.

NEUROLOGY/PSYCHIATRIC DICTATION #1
OFFICE NOTE (1:00)
BRIEF SUMMARY OF CHART

The patient has had personality difficulties all of his life, as well as severe
somatic and psychosomatic
disorders. Patient is a 47-year-old white man discharged from the Army because of
conversion reactions.
After discharge apparently he had hysterical paralysis of legs. He became
psychotic and was transferred
to a succession of nursing homes with a diagnosis of schizophrenia. He developed
an extremely acute
psychotic episode here. There was no euphoria at any time.
INTERVIEW
Patient�s outstanding characteristic1 was his inability or disinclination to
answer direct questions or talk in
specific terms. He blames himself for everything. He is fearful lest he cause
trouble, and the facies is2
tense and anxious.
DIAGNOSIS
Schizophrenia, catatonic, in partial remission.
814 characters
1 The dictator says �characteristics.�

2 The noun facies is singular and takes a singular verb. Edit are to is for
subject-verb agreement.

OFFICE NOTE (2:30)
SUBJECTIVE
Patient is a 24-year-old Caucasian female here for complaint of headache,
backaches, and bad nerves. She
has not had a Pap smear in over 1 year. She states that she is having difficulty
sleeping. Her back has been
sore ever since she had her bilateral tubal ligation. She has not been having any
problems with pain in her
legs or weakness. She is doing sit-ups; however, she is doing straight-leg sit-
ups, and she is also doing
stretching exercises for her back. She also has muscle tension in the shoulders
and neck and towards the
end of the day is having pressure-type headaches in the temples. This is partially
relieved by massaging
the neck and shoulders and taking Tylenol. She has continued to do breast exams,
and there has been no
change in the left upper outer quadrant mass.
OBJECTIVE
Back: There is no spinal tenderness; however, there is some tenderness in the
lower paraspinal muscles
and the trapezius. Neurologic:1 Patient is alert, oriented x3. Conversation is
appropriate. Cranial nerves 212
are grossly intact. Motor and sensation are2 intact. Extremities: There is no
weakness or paresthesias.
Deep tendon reflexes in the Achilles and patella are 1+ and symmetrical.
IMPRESSION
1.
Health maintenance. Patient has not had a Papanicolaou (Pap)3 smear in over 1
year.
2.
History of breast mass, which is not enlarging.
3.
Muscle contraction headaches.
4.
Low back pain.
PLAN
1.
Have advised patient to do her sit-ups in the bent-knee position, continue her
stretching exercises, and
use her stationary bike for at least 20 minutes a day 3-4 times a week at
approximately 70% maximal
heart rate.
2.4 Have also advised that she attempt to find someone to watch her children at
least once a week so she
can get out and relax; however, she does not feel that she can find anyone that
would be willing to do
this.
3.
I have advised patient to come back in 1-2 weeks for breast exam and Pap smear.
1922 characters
1 Expand brief forms in headings, although in a SOAP note, a brief form may be
acceptable.
2 Edit is to are for subject-verb agreement.

3 Expand brief forms in diagnoses or impressions, although in a SOAP note, a brief
form such as Pap smear may be
acceptable.
4 Numerals are added for consistency in format.

This is a 69-year-old right-handed man who was referred to us. He had been
complaining of gradual
worsening of his shuffling gait over the last 5 years. Recently he has developed
some back pain associated
with the shuffling gait and a shrinking handwriting. He was seen by a chiropractor
who suggested a
consult with a neurologist. He was diagnosed with Parkinson�s1 disease. His gait
progressively became
worse over the last 5 years, and he started falling more consistently. Over the
last 6 months, his balance
worsened and he felt light-headed, especially with walking. He also developed
urinary frequency; thus, a
tentative diagnosis of normal-pressure hydrocephalus was implicated. The patient
received a lumbar drain
and, reportedly per Neurology,2 improved significantly. As such, he was referred
for a
ventriculoperitoneal (VP)3 shunt.
867 characters
1 Alternative: Parkinson. The use of the possessive form of eponyms is acceptable

3 Expand an abbreviation on first use and place the abbreviation itself within
parentheses.

OFFICE NOTE (1:00)
CLINICAL HISTORY
Patient is a 29-year-old woman with hydrocephalus since birth with a complex shunt
history including
many, many operations for revision. She reports increasing headache and fluid
collection in the left
suboccipital region underlying her incision, where there is a shunt valve
previously connected to a pleural
distal catheter. She reported hearing a pop on head-turning and subsequently
noticed the fluid collection.
CT scan demonstrated some increase in ventricle size. An AP chest film
demonstrated evidence for
migration of the pleural catheter, likely migrating to the intrathoracic space
with disconnection from the
distal end of the valve in the left suboccipital region.
DIAGNOSIS
Left ventriculopleural shunt disconnection/malfunction.
776 characters

PHYSICAL THERAPY PROGRESS NOTE (2:30)
CURRENT MEDICAL HISTORY

This 70-year-old white male was admitted from home with diaphoresis, left facial
droop, and problems
with speech. Patient had suffered a brain stem infarct resulting in mild left
hemiparesis, vertigo, vocal
cord paralysis, and pharyngeal dyskinesia. Patient is also now being considered
for a gastrostomy due to
high risk for aspiration.

Includes pigment detachment in the right eye and macular degeneration. He had a
nonunderlying
transmural myocardial infarction several years ago and also has hypertension.
SOCIAL HISTORY
The patient lives alone in an apartment building which has 10 stairs and railings
to enter. His daughter
frequently checks on him.
EVALUATION
The patient was evaluated at bedside.
Communication: Patient is able to follow simple as well as complex instructions
well. He is alert and
oriented x3. His speech is slightly slurred but understandable with repetition.
Observations: The patient is extremely congested and is coughing frequently during
the evaluation,
producing greenish-yellow phlegm.
Range of Motion: All ranges are within normal limits.
Strength: Bilateral upper extremities are 4 to 4+ out of 5 throughout. Only
minimal strength deficits were
noted in the left lower extremity. Generally he has 4 to 4+ strength on the left
side and 4+ to 5 strength on
the right.
Bed Mobility: He is able to roll to his right or left side independently and needs
only minimal assistance
to achieve a sit-to-supine transfer.
Sensation: Proprioception was tested, and the patient gave inconsistent responses
for both ankle
movements but was able to accurately identify all knee proprioception movements.
Gait: This also was not assessed since the patient is on bed rest.
Balance: Sitting balance is at least fair. Patient did not remain sitting for very
long due to complaints of
feeling shaky and tired.
Coordination: Patient has moderate coordination deficits in the left upper
extremity as compared to the
right upper extremity.
ASSESSMENT/PLAN
The patient was found unresponsive.1 Therapy is on hold for right now.
2114 characters

1 This sentence needs to be flagged to the dictator�s attention. The patient was
obviously responsive during the
examination�sitting up, rolling over, and following therapist�s various commands.

OFFICE NOTE (0:30)
A 69-year-old male who had a mass in the medial aspect of the right knee. This
enlarged and was
biopsied approximately 2 years prior to presentation. This reportedly demonstrated
a schwannoma with
considerable hemorrhage. At the time of his presentation, the outside slides were
reviewed, and our
pathologist confirmed the diagnosis of a benign nerve sheath tumor.
DIAGNOSIS
Soft tissue neoplasm, right medial thigh (presumed schwannoma).
454 characters

OFFICE NOTE (4:00)
This1 is a 44-year-old female with a complaint of chronic headaches since she had
a fall at work. Current
frequency is 4 times a month. She usually wakes up with this headache, and they
last approximately 16
hours. The character of the pain is throbbing, and it is located from the
postcervical area extending to the
eyes. Before the headache begins, she has a prodrome of pain in her back.
Associated features are
photophobia, flushing, and she must go to bed with this headache. She cites light
as a possible
precipitating or aggravating factor.
MILD IRRITATING HEADACHES

She had these when she was in her mid-20s, and they were only occasional. Current
frequency is about
one every 2 weeks. These headaches begin around noon and last for approximately an
hour, and she takes
Tylenol. The character of the pain is aching and throbbing. There is no prodrome.
There are no associated
features. She cites tension at work as a precipitating or aggravating factor.
PAST HISTORY
Her birth was normal. She did not have a problem with carsickness during childhood
nor did she have
unexplained abdominal cramps. She denies the following childhood illnesses:
meningitis, encephalitis,
scarlet fever, rheumatic fever. She had no head injuries as a child, and she was
never treated for emotional
illness.
HABITS
She does not drink alcohol. She states that it will not bring on or aggravate a
headache. She does not
smoke, and smoke-filled rooms will not bring on or aggravate a headache. She
drinks no caffeinated
beverages.
MEDICAL HISTORY
Her menstrual period began when she was 12 years old. It has been within normal
limits except for one
year when she had 1 period every 6 months. She had not related her headaches to
her cycles. She has
taken birth control pills, and they have not precipitated headaches. She took them
for 1 month and
experienced syncope on a daily basis. She took them for 3 months and developed
blood clots under her
fingernails. She has not entered menopause and takes no hormones. She denies the
following medical
problems: hypertension, stomach ulcers, pneumonia, hypoglycemia, glaucoma,
diabetes, and heart
problems. She has a history of asthma. Her last asthma attack was at age 23. She
has allergies to certain
foods such as wheat and corn. She had bronchitis.
SURGICAL HISTORY
Surgery for �carpal tunnel-like syndrome� on right hand and a cholecystectomy.
PSYCHIATRIC HISTORY
Marriage counseling, and she has had sessions at the family learning center with
her daughters.

ACCIDENTS IN ADULT LIFE
She was at work, and while climbing down a ladder, she fell off a milk crate. She
hit the back of her head
and her neck on the bottom shelf of a stainless steel table, and her back hit the
floor. Her right hand and
right thumb were bruised trying to break the fall. She was given a neck brace, and
her right arm was put
in a protective sling. She states that her headaches started immediately after
this accident.
FAMILY HISTORY
Her father is 70, and her mother is 65, and neither have a history of headaches.
She has 2 brothers who do
not have headaches. Her sister has had problems with posttraumatic headaches. Her
daughter has what
she calls �sick headaches.�
STRESS FACTORS
She cites problems at work.
VEGETATIVE SIGNS
She does not have problems falling asleep. She states she does has trouble staying
asleep due to the back
pain. She has no problems with her appetite, and her weight has remained stable in
the past year. She has
felt tearful and depressed lately because of problems with her health. She denies
having any thoughts of
wanting to die and has no problems with her memory.
MEDICATION ALLERGIES
Aspirin, which causes itching.
CURRENT MEDICATIONS
Darvon p.r.n. for pain, and Tylenol up to 6 a day,2 taking 3 at a time.
PAST MEDICATIONS
She has taken codeine for her back and also Darvon and Darvocet. Both of these
have been helpful. She
also has taken Voltaren, Soma, and Tylenol No. 3, and these helped for awhile with
her headaches.
PREVIOUS CARE
None listed.
DIAGNOSTIC TESTS
She had skull and neck x-rays after the accident but was not told the results.
4091 characters
1 The dictator says, �This is a headache history.� Alternative: HEADACHE HISTORY
as a heading.
2 The comma indicates the patient is taking 3 Tylenol at a time, up to 6 a day.

Patient is a 33-year-old woman, currently separated from her husband, who had been
in treatment with the
undersigned1 for agoraphobia with panic attacks. Recently her situation
deteriorated in that she developed
multiple symptoms of depression.
Attempts to treat this as an outpatient were unsuccessful.
On initial mental status examination, the patient presented without psychotic

signs or symptoms, and
there was no evidence of any organicity. She had multiple symptoms of depression
including insomnia,
loss of appetite with weight loss, crying spells, anhedonia, difficulty
concentrating, withdrawal, isolation.
She also complained of multiple anxieties. She had recently become almost a
recluse.
Patient was treated with antidepressant medications and individual, group, and
occupational therapies.
She responded favorably to these treatments in that at the time of discharge she
had no significant degree
of depression and felt optimistic about her future.
A medical evaluation showed the presence of dyspepsia.
Laboratory studies were within normal limits except for elevated thyroid panel
which was felt to be
secondary to use of birth control pills.
At the time of discharge the patient was taking Xanax 0.5 mg 3 times a day and
Desyrel 100 mg nightly.2
Arrangements were made for appropriate outpatient followup and care.
FINAL DIAGNOSES
1. Agoraphobia with panic attacks by history and under treatment.

2. Major depression, single episode.
3. Elevated T3, T4, T7,3 secondary to use of birth control pills.
1531 characters
1 The dictator is referring to his own signature at the end of this report.
should be replaced with nightly or
every evening.
3 Alternative: T3, T4, T7.

The patient is a 73-year-old female who was admitted with the acute onset of
paralysis of her right leg.
The remainder of the history and physical examination is1 as described in the
admission note.
HOSPITAL COURSE
Subsequent to admission, chest x-ray was unremarkable. Initial CT brain scan only2
showed an area of
low attenuation in the right frontal area suggestive of prior infarction. Repeat
CT showed evidence of
recent infarction in the left posterior cerebral hemisphere near the midline. The
patient was seen in
consultation by the neurology section, and there was felt to be some evidence of
lower motor neuron
involvement. Cervical spine x-ray showed advanced degenerative disk disease of C3
and C7.
Myelography did show some posterior displacement of contrast in the cervical
region, but there was no
lesion that was felt to be consistent with a lower motor neuron deficit. CT of the
cervical spine showed
osteophyte formation but no critical cord impingement. Bilateral carotid
angiograms showed generalized
intracerebral atherosclerosis. Dorsal MRI was unremarkable. Electrocardiogram
showed sinus
bradycardia and nonspecific ST and T-wave alterations. Results of lumbar puncture
and admission
chemistry profile and hemogram were unrevealing. Blood sugars were elevated during
admission and
required supplemental doses of insulin for control. The patient was eventually
discharged to the rehab
center for further rehabilitation. She was left with a right lower extremity
paresis. She was on no specific
activity restrictions. Discharge medications include NPH insulin 24 units q.a.m.,
Zantac 150 mg b.i.d.
p.r.n.
FINAL DIAGNOSIS
1. Cerebral infarction.
1706 characters
1 Edit are to is for proper subject-verb agreement (�remainder . . . is�).
2 The word only modifies area and could be moved to after the verb showed for
clarity.

CONSULTATION (5:00)

This is an 80-year-old woman who was admitted to the intensive care unit for
pulmonary edema. The
pulmonary edema was treated. She also has had episodes of atrial fibrillation
which have been treated.
She is currently out of pulmonary edema and in normal sinus rhythm. During the
hospitalization she
developed a fever, and Hemophilus influenzae was cultured out of her sputa. She is
currently taking
ciprofloxacin for that infection. She is now afebrile. I am being consulted
because of her confusion. The
patient prior to admission lived in her home alone. According to the daughter, the
patient was doing all of
her own activities of daily living and was coping independently. As far as the
daughter knows, she had no
problems with confusion. She did have some mild memory problems. Apparently the
patient drank a great
deal of alcohol and smoked cigarettes. During this hospitalization her condition
of confusion has waxed
and waned. There are times when she has been more lucid than other times. Librium
was prescribed1
because of the concern for the patient developing delirium tremens. She has not
eaten very much during
the hospitalization.

The patient has alcoholism and has had cataract surgery and apparently has poor
vision. She has had
previous problems with congestive heart failure.
MEDICATIONS
Medications at home were none. Here in the hospital, she has received digoxin,
Lopressor, Isordil,
Librium, and Cipro for the above-mentioned problems.
SOCIAL HISTORY
As mentioned, she lives alone. She has 3 daughters. She drinks large quantities of
alcohol and smokes
cigarettes.
FAMILY HISTORY
Family history is noncontributory.
REVIEW OF SYSTEMS
Review of systems is impossible. The patient is unable to give a history.
VITAL SIGNS:3 The blood pressure is 130/80, respirations 24. Patient has a
temperature of 95.2. Pulse is
73 and regular.
GENERAL: Patient is very confused, somnolent, difficult to arouse.
SKIN: Exam shows poor turgor with suggestion of dehydration. Mucous membranes are
dry.
HEENT: HEENT is unremarkable except for the dry mucous membranes of the mouth.
LUNGS: Lungs show an occasional rhonchus.
CARDIAC: Cardiac exam shows a grade 2/6 systolic ejection murmur heard at the
apex.

BREASTS: No masses.
ABDOMEN: Abdominal exam is nontender. Normal bowel sounds. No organomegaly.
EXTREMITIES: Patient�s extremities show no edema presently. She has very poor
peripheral vascular
pulses.
NEUROLOGICAL: Neurologically there are no focal signs, but the patient is very
confused. She is not
oriented to person, place, or time or situation. Her memory is extremely poor.
LABORATORY DATA4
The current EKG shows a normal sinus rhythm. The chest x-ray, when initially
admitted, showed
cardiomegaly with pulmonary venous hypertension, mild pulmonary edema, small
bilateral pleural
effusions. A repeat film showed pleural effusions bilaterally. Initial lab data
showed a white count of
19,200. A hemoglobin is 12.5 with an MCV of 102.6. The hematocrit is 38.2. The
initial SMAC showed
an elevated glucose, but subsequently the glucose normalized at 88. Her albumin
was5 low at 3.5 initially
and then has further decreased during the hospitalization. Liver function tests
have been normal.
ASSESSMENT
I believe this patient has delirium with possible underlying dementia. This is
likely secondary to a
combination of factors including alcohol withdrawal, infection, change in her
environment with some
features of sensory deprivation, possible cerebral infarct or subdural hematoma,
or possibly due to an
accident in an alcoholic state. Also other factors would include medication that
might be adding to the
confusion and of course her poor nutritional status.
RECOMMENDATIONS
I would obtain a CT scan, a serum ammonia level, B126 and folic acid levels,
thyroid profile, RPR, and
obtain a calorie count. I would discontinue the Librium and consider using a
feeding tube if the patient is
unable to ingest adequate calories.
3988 characters
1 Edit placed to prescribed for correct usage.

5 Change is to was for proper verb tense.
6 Alternative: B12.

CONSULTATION (5:30)
This is a 40-year-old man who1 I saw initially, and at that time I was given a
history that the patient had
been hydrocephalic from birth, that he had never had any active intervention or
surgical treatment for it
because it was felt that he had reached a state of arrest of the hydrocephalus and
that he had therefore
lived with this condition up to the present time. He had grown to have obviously
quite a large head size
but was described by his brother as having had good memory, good math ability, and
a satisfactory ability
to cope with activities of daily living. His brother assumed his guardianship
because there were some
areas of intellectual deficit present, however. I saw the patient because there
was a problem of increasing
aggressiveness and hostility, and the family had become fearful for its physical
welfare. He had had CT
brain scans, and both of them showed advanced hydrocephalus secondary to atresia
of the aqueduct but
without any interval change between the scans. His history and examination did not
seem to indicate that
he was undergoing any decompensation of the hydrocephalus, but rather that the
problem was one of
personality change and the development of aggressive and hostile personality. He
was treated with Haldol
and Valium, and a good effect was achieved, and apparently this tendency was
modified to such a degree
that he was kept at home and created no further problems.
I did not see him again until a couple of weeks ago when he was confined to this
hospital with a history
that, over the preceding couple of months, there had been a significant
intellectual decline with almost
complete loss of the good memory that he had had, a complete loss of the math
ability that he had had, a
loss of his recognition of family and friends, and that he had descended into a
state of confusion,
disorientation, and seeming idiocy. During that time he had also complained
repeatedly of headaches,
which was an uncommon thing. At the point that he entered the hospital, however,
it was because of a
febrile state and gastroenteritis. A variety of studies were2 done without the
cause of the febrile state ever
having been fully or clearly identified. Nonetheless it resolved. He also had a
repeat CT brain scan which,
when compared with scans, again showed advanced hydrocephalus secondary to
aqueduct atresia but
without any evidence of change whatever. Therefore the source of the confusion and
disorientation was
not immediately evident. The patient was then transferred to this facility for
rehabilitation. He has now
been afebrile for some period of time. His white blood count and differential have
returned to completely
normal. His sedimentation rate is only 30. Nonetheless he is still intellectually
deficient3 when compared
with the premorbid state of some 3-4 months ago.
Yesterday4 I spent a considerable amount of time with the patient�s brother and
sister-in-law, both of
whom have been intimately acquainted with him for many years, and both of whom
feel very strongly
that the decline in cognitive functioning is a very real one, has been very
profound, and who feel that it
has not improved since the febrile state was eradicated. We discussed the nature
of hydrocephalus at
length, the fact that those cases which are due to atresia of the aqueduct can in
fact decompensate at any
time in life, and it was pointed out that the clinical picture of decompensation
of the hydrocephalus is so
strong that one must overlook the fact that changes in the CAT scan could not be
appreciated. Perhaps the
degree of abnormality was so severe to begin with that such changes are just
simply not readily evident.
In any event, it is certainly unclear as to whether inserting a
ventriculoperitoneal shunt at this time would
return him to his status of some 3-4 months ago. That possibility exists, however.
I pointed out that the

insertion of the shunt in the face of such advanced hydrocephalus is sometimes
followed by the
production of spontaneous subdural hematomas and other kinds of complications.
Nonetheless the
prospect of returning the patient to some semblance of his former self appeals
strongly to the family, for
the only alternative will be to institutionalize him, something which they would
like to avoid. Therefore,
in the face of unknowns and uncertainties, and in the face of possible serious
side effects, etc., a mutual
agreement was reached that we would insert a ventriculoperitoneal shunt and hope
that it will provide an
opportunity for improvement. That will be scheduled for the earliest opportunity.
4582 characters
1 For grammatical correctness, who should be edited to whom.

2 A variety takes a plural verb, which is correctly dictated.
3 The dictator says deficit but means deficient.
4 On the job, you would change yesterday to a date. When referring to a day in a

CONSULTATION (4:30)
Was seen in consultation at 2140 hours for a chest evaluation.
The patient is unable to give any history because of a comatose status and also
because of an endotracheal
tube in place.
She apparently was in an automobile accident about 24 hours ago and was brought
here by ambulance
with head injuries, multiple fractures, intra-abdominal bleeding, and facial
lacerations.
She is presently in a coma, unable to respond to spoken voice, but she does
respond variably to painful
stimulus. The examination at this time reveals that there is considerable edema
about the eyes and face.
She has an endotracheal tube in place and a mouth gag in place as well. Her
nasogastric tube is attached
and on low suction and is working correctly. Her eyes deviate down with the right
eye turned in towards
the inner canthus. The left eye is deviated down in midposition. She has facial,
nasal, and orbital1
incisions that have been repaired and appear clean. The endotracheal tube is
functioning well, and it was
pulled back about an inch, as it appeared to be down too far by x-ray. The neck is
supple. There is no
significant neck vein distention. She has good carotid arteries2 and no bruit. On
examination of the chest,
the right chest expands and contracts quite well.3 The left is almost flail with
asymmetrical and only
minor movement. There is subcutaneous emphysema present over the lateral portion
of the left chest. The
air exchange is very poor on the left, and it is4 quite good on the right. The
heart is not enlarged. The heart
rhythm is regular sinus, no murmurs are heard, and there is no rub. The breasts
are soft. No masses can be
felt. She has had a recent abdominal incision where she had some repair work done
to the spleen, and a
dry dressing has been applied. Bowel sounds are quiet. Femoral pulse is good, but
the pulse in the feet is
poor and can only be obtained by Doppler. The left leg is in traction, and the
left foot is edematous.
IMPRESSION
Head injury with skull fractures. Comatose state. Laceration of the face, upper
eyelid, and the cheek on
the left. Fracture of the left clavicle and fractures of the 2nd through the 7th
ribs on the left side. She also
has a fractured pelvis and fractured left lower leg by x-ray. She also has
subcutaneous emphysema over
the left lateral chest with poor excursion on the left. I see no evidence of
pneumothorax at this time on the
present chest x-ray.
It is my recommendation that we continue her on the respiratory assistance with

the same parameters, and
we want to make sure that her endotracheal tube stays up where it is now. We need
to check another chest
x-ray in the early morning for comparison, particularly in regard5 to pneumothorax
and also for
endotracheal (ET)6 placement, and we also should recheck her arterial blood gases
in the morning.

It is my impression that her head injuries are more serious than her present chest
status; however, we must
be sure she does not develop any atelectasis, pneumothorax, or intervening
infections. I will be glad to
follow with you.
3055 characters
1 The dictator means periorbital rather than orbital.

2 The dictator means arterial pulses rather than arteries.
3 Edit the dictated adjective good to the adverb well, modifying expands and
contracts, for proper usage.
5 Edit regards to regard.
parentheses.

HISTORY AND PHYSICAL (2:30)
CHIEF COMPLAINT
Slurring of speech with right facial weakness and drooping.
PRESENT ILLNESS
This1 83-year-old white male experienced weakness, slurring of speech, and
drooping of the right side of
the face. He presented in the emergency room. He was able to see. He was aware of
what was happening
to him. There have been no previous experiences such as this. He has a long
history of rather severe
essential hypertension. He denied chest pain during this episode. There was no
loss of vision. There was
some dizziness. There has been no history of trauma to the head.

Long history of angina pectoris. Documented gallstones. Documented right carotid
stenosis. Small aortic
aneurysm is present. Transurethral resection (TUR).2 Longstanding essential
hypertension. Severe burn to
abdomen with resection of carcinoma of the abdominal wall approximately 6 months
ago. There is
macular degeneration, and he is an ex-smoker, having quit 12 years ago.
SOCIAL HISTORY
Retired pharmacist and is married.
MEDICATIONS
Medications have consisted of aspirin 1 daily.
SYSTEM REVIEW
General: Head: See Present Illness.
Heart: There has been no recent exertional chest pain. There is mild dyspnea on
exertion.
Lungs: No severe cough, wheezing, or hemoptysis.
Gastrointestinal (GI):3 No vomiting or diarrhea. No abdominal pain.
Genitourinary (GU): Gets up at night 2-3 times. Has a fair stream of urine without
discomfort.
VITAL SIGNS: Blood pressure 230/118 on admission in the emergency room,
respiration 18, pulse 76,
temperature 98.7. Weight estimated at 150. Height estimated at 5 feet 6 inches.5
GENERAL: Elderly white male in acute distress.
HEAD: The pupils are equal and reactive. Slight weakness of the right face noted.
HEART: A6 1-2/6 precordial murmur, systolic, without gallop. Bilateral carotid
bruits are present.
LUNGS: Moderately decreased breath sounds bilaterally without rales.
ABDOMEN: Healed extensive scar over abdominal wall. No masses palpable. No
distention.
RECTUM: Not examined.
EXTREMITIES: Peripheral pulses are absent below the femorals. Patient moves all
extremities. Reflexes
are symmetrical, and Babinski is absent.

IMPRESSION
1. Hypertensive encephalopathy with transient ischemic attack (TIA).7

2. Long-standing essential hypertension.
3. Arteriosclerotic heart disease (ASHD)8 with recent infarction.
4. Rule out acute myocardial infarction.
2408 characters
Add �this� or �an� to avoid starting the sentence with a number.
Expand an abbreviation on its first use and place the abbreviation within
parentheses.
Expand abbreviations in headings.
Expand brief forms in headings.

5 Foot is correct only in an adjectival use such as 6-foot man; for other uses,
feet is correct. Write out nonmetric
units of measure (foot, inch); do not use the symbols for foot and inch. Do not
place a comma between units of the
same dimension.
Add the article a to avoid starting the sentence with a numeral.
Expand abbreviations used in diagnoses.
Expand abbreviations used in diagnoses.


This 74-year-old woman has complained of a severe headache with nausea and
vomiting, and after having
a fever of 102.5 for 5 days, she had begun to develop discomfort in her right
occiput which hit her with
staggering sharp pains for the last 3 days prior to admission. She would have 30-
minute episodes of pain
which would ease. Several days before admission, she developed shaking chills and
vomiting which had
subsided at the time of admission. She is continuing to have nausea but no
vomiting.

Felt to have probable mild bronchiectasis with recurring chest infections. History
of compression
fractures of lumbar spine in the past. Tonsillectomy at age 12, appendectomy age
25. No other serious
illnesses.
SOCIAL HISTORY
She is widowed.
FAMILY HISTORY
Her father died of liver cancer.
MEDICATIONS
No medications.
ALLERGIES
No known drug sensitivities.
GENERAL: On physical examination, she is a well-developed, pale-appearing white
woman who appears
in considerable pain.
HEENT: HEENT is unremarkable except for tenderness over the right occipital area
of the scalp and also
the right suboccipital area.
NECK: There is a trigger area that is quite tender. No nodes in the neck,2 no
bruits, no thyroid
enlargement.
HEART: Heart has a regular rhythm. No gallops or murmurs.
LUNGS: The lungs reveal a few basilar rales.
ABDOMEN: Abdomen is negative. No adenopathy.
GENITAL AND RECTAL: Genital examination and rectal examination were3 not done at
this time.
NEUROLOGICAL: Cranial nerves 2-12, sensorimotor, and reflex examinations are
intact. No
rombergism. No Babinski.

IMPRESSION4
1. Occipital neuralgia.
2. Probable acute gastroenteritis.
1710 characters

2 Alternative: Edit out the redundant dictation �in the neck.�
3 Edit was to were for subject-verb agreement.
4 Number diagnoses when more than one is dictated.

ADMITTING DIAGNOSES
1. Acute cerebrovascular accident (CVA)1 with expressive aphasia.

2. Hypertension.
4. Foot ulcer.
DISCHARGE DIAGNOSES
1. Left lower posterior parietal lobe cerebral infarction with receptive aphasia.
2. Hypertension.
4. Foot ulcer.
OPERATIONS
None.
COMPLICATIONS
None.
Stable without further advancement of neurologic deficit and possibly some
improvement.
BRIEF HISTORY AND PHYSICAL

This is one of several hospital admissions for this 60-year-old man with known
hypertension and diabetes
that had been well controlled on an outpatient basis. While at work on the day of
admission, he apparently
became acutely confused and unable to communicate. He subsequently was brought to
the emergency
room by his wife, where he was evaluated and admitted. Physical exam upon
admission is as recorded in
the admitting history and physical. Pertinent physical findings were essentially
limited to the neurologic
exam, where he was noted to have paucity of spontaneous speech. There were
paraphasic errors.
Sensation and finger-nose testing was intact.
HOSPITAL COURSE
CT scan initially revealed only an old right hemispheric lacunar infarct. He was
admitted to the intensive
care unit, and neurologic consultation was obtained, felt the patient had a
receptive aphasia, and
recommended supportive treatment initially. The patient stabilized and was
subsequently transferred to
the progressive care unit and later to the ward. At no time did he have any
significant motor deficit. The
patient�s receptive aphasia remained quite severe although there were some signs
of slight improvement
by the time of discharge. Additional evaluation included a repeat CT of the head
which revealed a recent
infarction in the left lower posterior parietal lobe compatible with the patient�s
neuro2 deficit. He was
started on aspirin 1 tablet daily. Additionally, carotid ultrasound studies were
obtained which were
reported to be unremarkable. Finally, echocardiogram was obtained which revealed
normal left

ventricular function, normal aortic and mitral valve leaf3 opening, no mitral or
aortic regurgitation. There
was an increased echodense area in the posterior atrial side of the mitral valve
of unclear etiology. It was
thought to possibly represent increased calcification, and although it was
unlikely, a thrombus could not
be absolutely excluded.
The patient did have a small foot ulcer which has been present for many months,
and this was treated
conservatively with Betadine and dry gauze dressings and had improved dramatically
by the time of
discharge.
LABORATORY DATA
CBC, PT, PTT were normal. Profile was also essentially normal except for a blood
sugar of 140.
Urinalysis initially revealed trace bacteria; however, urine culture revealed no
growth. Chest x-ray
showed no acute lung pathology, and electrocardiogram showed left anterior
fascicular block and
nonspecific ST and T-wave changes.
By the time of discharge, the patient appeared entirely stable with good control
of his blood sugars and
blood pressures. He appeared neurologically stable to slightly improved. It was
therefore elected to
discharge him and follow him on an outpatient basis.
INSTRUCTIONS UPON DISCHARGE
1. Continue 1500-calorie, low-salt diabetic diet.

2. Follow up with speech pathologist.
3. Activity to include short walks with plenty of rest.
4. Continued followup with podiatrist.
5. Follow up in my office approximately 1 week after discharge.
6. Call me immediately if any problems arise.
7. Medications: Glucotrol 5 mg daily,4 aspirin 1 tablet daily,5 Wytensin 4 mg
t.i.d.
3615 characters

parentheses.
2 The dictated neuro is an acceptable brief form. Alternative: neurologic.
3 The correct anatomic term is leaflet.
4 The dictated �q.d.� is on the list of dangerous abbreviations and should be
replaced with daily.
5 The dictated �q.d.� is on the list of dangerous abbreviations and should be
replaced with daily.

ELECTROENCEPHALOGRAM REPORT #1 (1:00)
DESCRIPTION
A fairly well-maintained alpha rhythm averages about 10 c/sec and 30 mcV or less
in the parieto-occipital
derivations. At rest there are1 some occasional theta activity ripples in both
temporal regions with some
spread to the anterior and posterior hemispheres. No definite lateralization can
be made out. Three
minutes of hyperventilation results in some scattered theta activity over both
hemispheres, but there is no
breakdown or buildup.
INTERPRETATION
A small amount of slow activity centering around both temporal regions
constitutes2 a mild and
nonspecific electroencephalogram (EEG) abnormality.
628 characters
1 Edit is to are for subject-verb agreement (�ripples . . . are�).

2 Edit constitute to constitutes for subject-verb agreement (�amount . . .
constitutes�).

ELECTROENCEPHALOGRAM REPORT #2
DESCRIPTION
Initially the patient is awake, and there is a fairly well-maintained alpha rhythm
centering around a
frequency of 9 c/sec and averaging less than 30 mcV in the parieto-occipital
derivations. Soon thereafter,
drowsiness and light sleep occur, and the remainder of the tracing alternates
between this state and brief
waking periods. Infrequently, small sharp waves and spikes appear focally in the
left temporal region
during drowsiness and light sleep. Otherwise, the tracing is free of dysrhythmia.
INTERPRETATION
This electroencephalogram (EEG) shows infrequent sharp waves and spikes focally in
the left temporal
region during drowsiness and light sleep.
675 characters

1The patient was admitted to progressive care unit (PCU) for observation. He was
started on aspirin 1 tab
p.o. a day and Persantine 25 mg p.o. t.i.d. No EKG changes were noted. The 2-D
echo done to evaluate
his systolic ejection murmur in the aortic area essentially showed some mild
thickening of the aortic
valve; however, this had a good opening excursion, and no evidence of aortic
stenosis was noted. There
was a trace of aortic insufficiency suggested in the Doppler studies. The mitral
valve was within normal
limits. Normal left ventricular function without any aneurysm or masses or
thrombus. The left atrium was
within normal limits. A carotid Doppler study revealed evidence of relatively mild
atheromatous disease
involving the right extracranial carotid systems. No hemodynamically significant
lesions were noted,
however. Patient�s motor strength improved of his left upper extremity. His SMA-24
revealed a normal
calcium of 9.3 with a phosphorus of 3.2. His blood pressure stabilized at 102/60
or 120/60.2 His sed rate
was 41. A repeat CAT scan showed some chronic atrophic changes. There was3 no
definite CT evidence
of a recent infarction. However, in view of the patient�s definite left arm
weakness, the diagnosis at this
point was cerebrovascular accident (CVA)4�presumably lacunar infarct.
The patient was discharged in stable condition. He was sent home with aspirin 1
tablet p.o. a day.
Persantine was discontinued. He was advised to see me in 10 days post discharge
for a followup.
DISCHARGE DIAGNOSIS
1. Cerebrovascular accident (CVA)�lacunar infarct.

2. Hypertension.
1585 characters
1 Clinical Resume is another name for the Discharge Summary; there is no need to
transcribe this.
2 Repeat the common denominator in expressions with slashes.
3 Edit were to was for subject-verb agreement (�evidence . . . was�).
4 Expand an abbreviation on its first use and place the abbreviation in
parentheses.

OFFICE NOTE (4:30)
IDENTIFYING INFORMATION
The patient is a 39-year-old, never-married Hispanic male.
MANNER AND APPEARANCE

The client presented with a pleasant body odor. He was wearing eyeglasses which
were very dirty and
repaired in several places with silver duct tape. There was no smell of alcohol on
his breath, and his eyes
did not appear to be glassy.
CURRENT SITUATION
The client lives in a house with his sister and brother-in-law. He has not worked
for the last 2 years. His
interests and hobbies include watching television all day, and he does some
drawing. Does like to go for
walks.
DAILY ACTIVITIES
Gets up in the morning and feeds the animals. He takes out the trash. Gets up
about 6 a.m. Helps his sister
with the chores around the house. He does dishwashing and makes his own bed, cuts
the grass, and does
yard work. He does watch the television for approximately 8 hours a day, usually
in the afternoon and
evening. He does not cook or drive a car.
SOCIAL HISTORY
He has 5 younger brothers and 1 elder sister. When asked to describe his brothers
and sisters, he states,
�We don�t see each other� other than the sister that he is living with at the
current time. He was unable to
give any significant details about his parents. He says that when he was small, he
and his brothers and
sisters were taken away because the parents were not taking care of them. They
were all put in foster
homes. The client himself was put in a foster home by himself without a sibling.
He states he began using
alcohol at the age of 19 and drinking every day.
INTELLECTUAL FUNCTIONING
The client was administered the WAIS-R and obtained a verbal IQ of 72, which is in
the 3rd percentile,
and a performance IQ of 72, which is in the 3rd percentile. His full scale IQ of
71 places him in the
borderline range of intelligence. The client scored as below:
Verbal test information: 7
Digit span: 2
Vocabulary: 7
Arithmetic: 5
Comprehension: 4
Similarities: 3

PERFORMANCE TESTS
Picture completion: 7
Picture arrangement: 4
Block design: 5
Object assembly: 4
Digit symbol: 1
Patient was also administered WAS-R and obtained the following memory index:
Verbal memory: 75
Visual memory: 87
General memory: 78
Attention and concentration: 54
Delayed recall: 81
PSYCHOLOGICAL FUNCTIONING
Client was oriented to person, place, and time. His affect was blunted and
consistent with a depressed
mood. His memory for immediate events appeared impaired. Recent and remote
appeared to be adequate.
There is no evidence of any flight of ideas, loose associations, delusions,
hallucinations, or any psychotic
thinking. Judgment appears poor. His insight is limited. There is no evidence of
suicidal or homicidal
ideation.
DIAGNOSTIC IMPRESSION
AXIS I: Alcohol dependency.
Secondary diagnosis: Major depression, recurrent, moderate.
AXIS II: Borderline intellectual functioning.

Secondary diagnosis: Personality disorder.
CONCLUSIONS AND RECOMMENDATIONS

The client�s level of intellectual functioning and short-term memory deficit will
make it difficult for him
to do work-related activities. His alcohol dependence probably would be the major
factor in his inability
to hold down a job. It is felt that this is probably heavily related to his
depression. Alcohol abuse appears
to be chronic, and he has attempted some treatment; however, this has been
generally unsuccessful. He
denies ever using antidepressant medications such as Zoloft, Wellbutrin, or even
Prozac. We first must
get his alcohol intake under control and then will consider starting him on one of
these newer
antidepressant medications.
3546 characters
ADMITTING DIAGNOSIS
Altered mental status. Rule out sepsis.
FINAL DIAGNOSIS
1. Urinary sepsis.
2. Altered mental state secondary to severe hyponatremia.
3. Hydrocephalus secondary to aqueductal stenosis requiring ventriculoperitoneal1
shunt with multiple
revisions over the last several years.
4. Status post fracture of the right hip requiring pinning.
HISTORY2
The patient is a 76-year-old gentleman, recently discharged from having a hip
fracture pinned about 1
week prior to this admission. He was doing well at home until he became acutely
unresponsive on the
morning of admission. He was admitted to the hospital through the emergency room
because of stiffness
in his neck. Lumbar puncture showed clear spinal fluid. He was admitted for
stabilization with
intravenous antibiotics and3 to rule out the possibility of sepsis.
PERTINENT PHYSICAL FINDINGS

Temperature 97.7, pulse 59 and regular, blood pressure 160/96. Cardiovascular exam
showed4 a grade 2/6
systolic murmur greatest at the apex. Neurological exam: Patient was disoriented
and unresponsive except
to painful stimuli.
PERTINENT LABORATORY DATA

CAT scan of the brain shows decompression of the ventricles with a shunt in place
and apparently
working well. There are two sites of old right cerebral infarction apparent that
were5 present on previous
scans. A portable chest x-ray shows moderate cardiac enlargement and no change
since the previous
study, and a perfusion lung scan was negative. Cranial magnetic resonance imaging
confirmed that
multiple foci of infarcts were present, particularly within the deep white matter,
associated with the
shunt�s positioning. There was no real change since the previous exam.
Echocardiogram shows very
slight sclerosis and thickening of the aortic leaflets, otherwise normal. This was
a very technically limited
study. Blood gases showed a pO2 of 106, pCO26 of 41, and pH of 7.40. Admitting
white count was 10,500
with a left shift of 84% segs. Hemoglobin was 12.7, hematocrit 39.0. Spinal fluid
analysis for bacterial
antigen detection was negative for B strep7 and Neisseria meningitidis. Admitting
serum sodium was 135.
His serum sodium dipped to 122 and improved to about 130 just prior to discharge.
Urinalysis on
admission showed 50-75 WBCs with 3+ bacteria. Spinal fluid was clear, colorless,
with 732 red cells and
1 white cell; this was a lymphocyte. The spinal fluid glucose and protein were
within normal range. Blood
cultures showed no growth. Urine culture grew out greater than 100,000 of
Escherichia coli (E coli)8
sensitive to everything. Spinal fluid cultures are negative.

HOSPITAL COURSE
Patient was placed on intravenous fluids for his dehydration. He was also placed
on intravenous Claforan
and gentamicin. By the 3rd hospital day, he became more alert. He began developing
diarrhea, and it was
thought that he could be developing antibiotic colitis; therefore, his gentamicin
and Claforan were
discontinued. He was placed on some Flagyl. The diarrhea improved, and the
patient�s eating began to
improve; however, he again became somewhat lethargic with a drop of his sodium to
122. It was felt that
this was most likely secondary to his intravenous fluids. He was seen in
consultation by Neurosurgery.9 It
was his10 impression that the patient�s shunt was functioning well and that this
was not the reason for his
altered mental status. Renal Medicine11 saw the patient with regard to his
hyponatremia. It was his
impression that his hyponatremia was secondary to excess free water administration
both p.o. and IV with
intermittent Lasix. He suggested p.o. fluid restriction and normal saline
intravenously. This improved the
patient�s mental status, and his serum sodiums returned to the 136 range just
prior to discharge. The
medications at the time of discharge included Betoptic 0.5% every 12 hours both
eyes, pilocarpine 1%
t.i.d. both eyes, Propine 0.1% b.i.d. both eyes, Procardia 10 mg t.i.d.,
Macrodantin 50 mg b.i.d.
3956 characters
1 Edit the dictated �ventricular-peritoneal� to the combined form

ventriculoperitoneal.
3 Insert and for clarity.
4 Change present tense to past.
5 Edit was to were for subject-verb agreement (�sites . . . that were�).
6 Alternative: PO2, PCO2.
7 Transcribe genus and species name in full on first use; however, it is uncertain
whether B strep stands for group B
strep or beta-hemolytic strep, so the report should be flagged.
8 The commonly dictated E coli should be transcribed in full genus and species
name on first use.
10 The dictator ambiguously uses �he� and �his� to refer to various consultants,
not the patient. Alternative: Change
appropriately to �the neurosurgeon�s impression . . .� or �the renal medicine
consultant�s impression,� etc.

CHIEF COMPLAINT
Mood swings.

This 38-year-old white male was originally incarcerated a few days ago due to
uncontrollable and
apparently psychotic behavior. There is claim in those records of assaultive
behavior towards the patient�s
father and towards police officials. The patient presently denies this degree of
behavior but admits that he
had been suffering from one of his periodic mood swings.
The patient and his father relate that he was diagnosed as having �manic-
depressive illness� about 15
months ago, but the patient feels that he has had problems consistent with this
since roughly his late teens
or early 20s. The patient had apparently been controlled on lithium and some other
medication but had
terminated the medication about a month or so ago with resultant deterioration of1
behavior by the
observation of others if not confirmed by his own self-observation.
FAMILIAL PSYCHIATRIC HISTORY2

There appears to be no known familial psychiatric history or neurological history.
ALLERGIES
Limited to iodine, which caused hives at the time of an intravenous pyelogram
(IVP).3
MEDICATIONS
Only those provided for treatment of his manic-depressive illness.
HABITS
Patient does not smoke and drinks very rarely and has not used street drugs.
PAST SURGERIES
Past surgeries include multiple surgeries by the patient�s otolaryngologist of the
left ear canal. The patient
estimates that he has had perhaps 7 surgeries. Other surgery is limited to a
tonsillectomy. Patient denies
any history of herniorrhaphy, appendectomy, cholecystectomy, etc.
PAST HOSPITALIZATIONS
Past hospitalizations are supposedly multiple according to the patient�s recall,
but he cannot remember
every one of them. The records here indicate that these were all limited to
considerations provoked by his
fibrous dysplasia of the left temporal bone. He was rehospitalized because of
concern that he might have a
meningioma or acoustic neuroma, but the abnormalities seen on x-ray and scan
proved to be due simply
to his fibrous dysplasia of the left temporal skull. He was readmitted for
reconstruction of the left auditory
canal and apparently had surgery for cholesteatoma of the left external auditory
canal. No other
hospitalizations are recorded at this hospital up until the present time.

FAMILY HISTORY
Family history reveals that mother and father are in good health. One brother is
apparently in good health.
There is apparently a maternal family history of increased incidence of cancer and
kidney problems, but
the details of this are not known with any certainty by the patient or his father,
who was present at the
time of this interview and exam. One aunt reportedly suffered from jaundice, and 2
cousins died in their
40s of breast cancer.
REVIEW OF SYSTEMS
HEENT: Head and neck history is positive for the patient�s recurrent left ear
surgeries due to fibrous
dysplasia of the left temporal skull. He also wears glasses and complains of
diplopia when he does not
have his glasses.
Hematologic: Hematologic history is negative for adenopathy or anemia or
coagulopathy.
Dermatologic: Dermatologic negative for recurrent rash or change in mole or growth
on skin.
Pulmonary: Pulmonary history negative for TB, asthma, pneumonia, dyspnea,
wheezing, or chronic
cough.4
Cardiac: Cardiac history positive for intermittent pleuritic chest pains as a
child, which have subsequently
resolved. No other cardiac history.
Gastrointestinal: Gastrointestinal history is entirely negative.
Genitourinary: Genitourinary history is similarly negative.
Musculoskeletal: Musculoskeletal history negative for any arthritis or
arthralgias.
GENERAL AND VITAL SIGNS: The patient is seen to be a blond, well-developed,
moderately thin
white male with a height of 5 feet 10 inches6 and a weight of 156 pounds, a pulse
of 86, a respiratory rate
of 20. Blood pressure not presently recorded.7
MENTAL STATUS: Patient appears mildly anxious and distractible but not actively
disoriented or
hallucinatory. He appears in no acute physical distress.
SKIN: Exam of the skin reveals no abnormality except for a small, roughly 1-cm3
cauliflower-like nevus
of the lower mid back. It is flesh tone in color. It has no suggestion of
malignancy.
HEENT: Eyes on exam reveal full extraocular movements (EOMs).8 Pupils are
symmetric. Ears reveal
intact hearing on the right. Cannot assess hearing on the left. Right tympanic
membrane and auditory
canal are normal. Left auditory canal is externally widened and ends in a blind
pouch. There is no passage
onto any tympanic membrane or inner ear. The left facial structure appears
generally swollen or
prominent or asymmetrically prominent. Mouth and throat reveal normal dentition,
tongue, palate, and
pharynx.
NECK: Neck is supple without goiter or adenopathy. Peripheral adenopathy is
notable for minimal (1+)
bilateral axillary adenopathy.
CHEST: Lungs are clear on auscultation, and back is not tender on percussion or
palpation. The cardiac
auscultation reveals a regular rhythm without gallop, rub, or murmur. There is no
pedal edema.
ABDOMEN: Abdomen is without organomegaly, mass, or tenderness.
RECTAL AND GENITAL: Exam of the rectum and of the genitalia is9 deferred.
NEUROLOGIC: Neurological exam reveals the above-noted features of anxiety and
distractibility in a
gentleman who otherwise, however, is oriented to place, person, and time. He is
cooperative. Cranial
nerves 2-12 are grossly intact symmetrically. Deep tendon reflexes are
symmetrically 1+. Babinski is

downgoing. The patient�s Romberg testing and gait are both entirely normal. There
is no tremor or
abnormal muscle rigidity.
LABORATORY DATA
Laboratory data at this time is limited to a normal EKG and a normal urinalysis.10
Additional laboratory
work has been ordered, and I will only add 2 tests of modest interest and
admittedly low expectable yield.
IMPRESSIONS
1. Bipolar affective disorder.

2. Fibrous dysplasia of left skull.
3. Left-sided hearing deficit due to #2.
4. Minimal adenopathy of likely no clinical significance.
6063 characters
1 Insert of for accuracy.

parentheses.
4 The superfluous �or�s� were edited out, but some might think they should remain
as indicative of the dictator�s
style.
7 Ignore the dictated paragraph instructions throughout the physical examination
for consistency in format.
parentheses.
9 Edit are to is for subject-verb agreement (�exam . . . is�).
10 The combined form urinalysis should be used rather than the dictated urine
analysis.

OBSTETRICS/GYNECOLOGY DICTATION #1
LETTER (0:30)
Dear Doctor:
Your patient is seen in our office today in followup for her ovarian carcinoma.
Continues to do extremely
well without complaints and on examination today is without evidence of recurrent

disease. In addition,
her Pap smears and CA-125 levels continue to remain negative. She is to return to
our office in
approximately 3 months for routine followup unless the laboratory tests ordered
today dictate sooner
evaluation.
Again, we would like to thank you for the opportunity to participate in the care
of this very pleasant
woman, and we will continue to keep you informed of her progress.
Sincerely,
623 characters
Edit �Return to our office� to �She is to return.� It is the patient, not the
referring physician, who is to return for
followup.

OFFICE NOTE (2:00)
SUBJECTIVE
Patient has had a long-standing problem with dysmenorrhea and also premenstrual
syndrome. She states
that her 2 last menstrual periods were very painful. She had lost the prescription
for the Anaprox DS. She
is trying to walk 15-20 minutes each day but states that this is not1 helping her.
She also admits to
drinking 3-1/2 pots of coffee a day as well as smoking 3 packs of cigarettes a
day. She also states that she
feels she is becoming more paranoid and agoraphobic but does not want to discuss
this with her
psychiatrist whom2 she will be seeing.
OBJECTIVE
Physical exam not done today.
ASSESSMENT
1. Dysmenorrhea with premenstrual syndrome (PMS).3

2. Caffeine and nicotine abuse.
3. Depression and paranoia.
PLAN
I have discussed with the patient at length measures to stop smoking, but she does
not want to try the
Nicorette gum nor does she want to decrease her caffeine amount at this time. She
is to start taking the
Anaprox DS 3 days prior to her menses and follow up with me in 2 months.
1021 characters

2 Edit who to whom for proper usage.

OFFICE HISTORY AND PHYSICAL EXAMINATION (3:00)
SUBJECTIVE
Patient is a 79-year-old white female who presents for a complete physical exam
with Pap smear. She was
seen 1 year ago in this clinic and had a physical exam and Pap smear at that time.
Patient has done well in
the past year and has had no specific complaints. She was complaining of
constipation last visit, but this
has resolved with the use of Metamucil. She has a history of colon polyps with
surgical treatment. She
had 3 Hemoccults which were negative for blood a few months ago. Patient is
followed for urinary
incontinence. She does still have some incontinence and is wearing a Depends at
night. She has a history
of thyroidectomy due to a benign growth. She is on Synthroid 0.2 mg daily, and she
has not had a testing
of her thyroid functions recently. Patient has been recently checked for glaucoma
by her ophthalmologist,
and she is in the process of being evaluated for a hearing aid.
OBJECTIVE
Patient is quite well-appearing. Her weight is 158. Blood pressure 130/78, right
arm. HEENT within
normal limits. Skin exam does show a 1-cm cystic-appearing lesion with a reddening
of the skin
overlying the lesion. She says that this has been present for 2 months but has
been decreasing in size.
There are multiple seborrheic keratoses on the trunk. Patient does have a history
of skin cancer. There is
an anterior neck scar from the thyroid surgery. No thyromegaly. No masses in the
neck. No carotid bruits.
No jugular venous distention (JVD).1 Lungs are clear to auscultation bilaterally.
Heart: Regular rate and
rhythm without murmur. Abdomen: Midline scar, status post colon surgery. No
hepatosplenomegaly.
Soft, nontender. There is an2 incisional hernia. There are 2+ dorsalis pedis
pulses. No edema in the ankles.
Reflexes are 2+ bilaterally, upper and lower extremities. There is normal muscle
tone and strength. Pelvic
exam shows an3 atrophic vaginal introitus. Cervix is without lesions. It is
somewhat friable. Pap smear is
taken. Vagina and external genitalia are without lesions. Rectal exam without
masses. Hemoccult
negative. There are some mild hypertrophic changes in both knees secondary to
osteoarthritis.
ASSESSMENT
A well 78-year-old white female.
PLAN
Health screen, UA, T3,4 resin uptake (RU),5 T4,6 and TSH are ordered today.
Mammogram is scheduled.
Patient will be maintained on her same medications. Spectazole cream to both feet
for tinea pedis. Refill
for patient�s Synthroid. Patient is to return to see me in 1 year for physical
exam and Pap smear or sooner
if needed.
2552 characters

parentheses.
Edit a to an before a vowel sound.
Edit a to an before a vowel sound.
Alternative: T3.
Expand unfamiliar abbreviations for clarity.
Alternative: T4.

OFFICE NOTE (1:00)
SUBJECTIVE
Here for OB check. She was seen in labor and delivery yesterday and the day before
when she had onset
of early labor. She was treated with Brethine 5 mg initially q.6 hours.1 When she
returned yesterday, it
was changed to q.8 hours2 because of the side effects. She has had no fluid
leaking from her vagina but
complains that she is still contracting with mildly painful contractions about
every 30 minutes. These
have not been sustained and are irregular. Yesterday,3 after being seen in labor
and delivery, she lost her
mucus plug. The fetus is active.
OBJECTIVE
Vaginal exam: Cervix is closed, thick but soft, at a -2 position. Fetus is vertex.
IMPRESSION
Premature labor at 35+ weeks.
PLAN
Send back to labor and delivery for monitor strip of the fetus and uterine
activity.
801 characters

3 On the job, you would change yesterday to a date. When referring to a day in a

OFFICE NOTE (1:00)
This is a 27-year-old gravida 0, para 0 female with tuberous sclerosis and severe
mental retardation with a
functioning level of approximately an 8-year-old. Presents with severe hygienic
problems related to
diarrhea which occurs on her menstrual cycles. She previously had been treated
with Depo-Lupron, which
increased her seizure activity, as well as birth control pills; however, these
were actually contraindicated
due to the patient�s prior history of stroke and hemiplegia. Her parents presented
with a request for
hysterectomy, and after several months of Lupron therapy, upon which the patient
did extraordinarily
well, we proceeded with an abdominal hysterectomy after consultation with her
neurologist. We decided
to leave 1 ovary in place as the patient has significant risk of osteoporosis and
actually had 2 recent
fractures of her feet. Estrogen replacement therapy was not considered in the
patient�s best interest except
in the form af a transdermal continuous-release patch.
1009 characters

OFFICE NOTE (1:00)
SUBJECTIVE
Feeling well. She still has a vaginal discharge as before delivery when she had
gardnerella. Her bleeding
stopped about 1 week after delivery. She has had no menses yet. Has not had
intercourse since delivery.
Requests oral contraceptives. In the past she took Ortho-Novum 7/7/7 with good
results, but at the time
she got pregnant she was taking pills only erratically.
OBJECTIVE
General: No distress. Pelvic: External genitalia, urethra, Bartholin�s, and
Skene�s1 glands all within
normal limits. She has a yellowish-white vaginal discharge. The cervix is closed.
Pap smear was obtained.
Uterus is nontender, of normal size. There is no adnexal mass or tenderness.
Rectal, normal tone. No
masses. Wet prep: 4+ clue cells. Many WBCs. No trichomonas and no yeast.
IMPRESSION
1. Gardnerella vaginitis.
2. Undesired fertility.
3. Normal postpartum exam otherwise.
PLAN
Flagyl 250 mg p.o. t.i.d. for 7 days for patient and her partner. Ortho-Novum
7/7/7 to start on the Sunday
after her next period, and she is to use a backup method of birth control for the
first month. She was also
given a prescription for Monistat, as she has had frequent yeast infections in the
past.
1190 characters
1 Alternative: Bartholin, Skene glands. The use of the possessive form of eponyms
is acceptable when it is dictated
or when it is preferred by the employer or client.

OFFICE NOTE (1:30)
This patient has had a problem with recurrent vaginitis which appears to be
refractory to
treatment. She has been treated multiple times with Flagyl in increasing doses and
has also been
treated for recurrent yeast infections with Monistat cream. The patient also
complains of chronic
pelvic pain that appears to be worse with sexual intercourse and largely in the
left lower
quadrant. It is interesting to note from the operative report of her bilateral
tubal ligation that the
patient�s left tube was surrounded with multiple adhesions requiring a vertical
skin incision.
The tube was noted to be bound down into the cul-de-sac with multiple adhesions.
It has been
recommended that the patient try Motrin for relief of pain; however, I believe
that her pain is
most likely secondary to adhesions. Should she fail a trial of antisteroidals with
continued and
worsening pain, she may warrant laparoscopy. At the time of this evaluation, the
patient�s
evidence of infection was not overwhelming, and I do feel that this patient has
been treated so
many times that she may be developing a resistance to Flagyl. It has been
suggested that the
patient not be treated for discharge alone but for evidence of infection.
Literature has been sent
regarding different treatment modalities for recurrent and refractory bacterial
vaginosis.
1347 characters

This 29-year-old woman came to the hospital at 39 weeks� pregnancy in early labor.
She was found to
have her baby in a breech presentation. She was counseled regarding the risks of
vaginal breech delivery
and agreed to proceed with cesarean delivery, having been counseled about the
procedure, alternatives,
and risks.
344 characters

Patient is a 37-year-old G11, now P31 Caucasian female followed secondary to

mitral valve prolapse and
mitral valve regurgitation. Patient was transported to our hospital secondary to
active labor at
4-cm dilation. Patient was admitted to labor and delivery. An epidural was placed
by Anesthesia2 without
any complications. Patient was noted to have a deceleration to the 90s. Cervix was
checked and noted to
be 8 cm dilated with a bulging bag of water. Artificial rupture of membranes was
performed. It was noted
that the patient had moderate meconium.3 The patient4 began to have late
decelerations down to the 80s to
90s which were repetitive. The late decelerations did not resolve with position
change, application of
oxygen, nor amnioinfusion.
773 characters
1 Alternative: gravida 11, para 3. Either the abbreviated or the spelled out form
may be used, whichever is dictated.
2 Capitalize a department name that is functioning as an entity.
3 The amniotic fluid had moderate meconium.
4 The fetus, not the patient, began to have late decelerations.

OFFICE NOTE (0:30)
SUBJECTIVE
Patient without complaints. No vaginal discharge. She states she has some
occasional spotting. Patient did
not receive an episiotomy.
OBJECTIVE
Physical exam revealed normal external genitalia. Cervix was intact. No
lacerations or lesions seen.
Normal-sized uterus, nontender. No cervical motion tenderness. No abnormal adnexal
masses
appreciated. Adnexa nontender.
ASSESSMENT
Patient is status post normal vaginal delivery approximately 6 weeks ago, doing
well. Normal exam.
PLAN
Patient advised birth control pills and for yearly Pap smears. Patient instructed
to use condoms until on
birth control.
626 characters

OFFICE NOTE (0:30)
SUBJECTIVE1
Patient is status post C-section, lower transverse incision. Patient doing well.
No complaints. No vaginal
bleeding. Pain is greatly diminished. She has no shortness of breath, leg
swelling, or tenderness. Patient
denies any vaginal discharge.
OBJECTIVE
Abdominal exam revealed a well-healed incision. No discharge. Good granulation
tissue. No areas of
fluctuancy2 palpated. Abdomen is nontender and soft with positive bowel sounds.
ASSESSMENT
Status post cesarean section,3 lower transverse. Wound healing well. No problems.
PLAN
Patient to follow up with physician in 1 month for 6-week postpartum care.
629 characters

2 Fluctuance is not a legitimate word; edit to fluctuancy.
3 The dictated �C-section� should be expanded in the diagnosis or assessment.


This is a 32-year-old white female who has a history of endometriosis, who
presents with a chief
complaint of dysuria, vaginal discharge with vaginal pruritus, and crampy
abdominal pain of 4 days�
duration. Patient states she has had a fever which has been progressive over the
last 3 days to a maximum
of 102-103�1 associated with chills. Patient is anorexic. She has not had any oral
intake since Thursday
and complains of myalgias, photophobia, headaches, and dizziness. Her last bowel
movement was on
Thursday. She normally has bowel movements every 2-32 days. She called her primary
MD on Thursday,
who placed her on Keflex 500 mg p.o. q.i.d. and Monistat vaginal cream for urinary
symptoms and
vaginitis. The patient describes the vaginal discharge as a milky white discharge
with foul odor. The
patient was seen in the ER this a.m., was given a fluid bolus, and patient was
encouraged3 to try p.o.
liquids, which the patient did, which was shortly followed by emesis.

Allergies:4 Patient has no known drug allergies but states that codeine makes her
nauseated.
Medications: Medications include Keflex 500 mg p.o. q.i.d., Monistat vaginal
cream, and Pyridium 200
mg p.o. t.i.d.
Surgical History: The patient has had a tubal ligation and was diagnosed with
endometriosis with
exploratory laparotomy.5
FAMILY HISTORY
Family history is significant for a father who had a myocardial infarction (MI)6
and died from heart
failure. Paternal grandfather has a history of MI, and maternal grandfather died
of prostatic carcinoma.7
There is no breast cancer or cervical cancer in the family.
SOCIAL HISTORY
The patient denies tobacco and alcohol use. Lives with her husband and 9-year-old
daughter and works as
a day care worker.
REVIEW OF SYSTEMS
Noncontributory.
VITAL SIGNS: Temperature of 102.6, pulse of 100, blood pressure 108/80 recumbent8
and 120/90
standing.
HEENT: Exam reveals a normocephalic, atraumatic head. Pupils equally round and
reactive to light and
accommodation. Extraocular muscles intact. Fundi benign without hemorrhage or
exudate. Without
photophobia. Tympanic membranes clear bilaterally. Oropharynx clear without
erythema or exudate.
NECK: Neck is supple. Full range of motion, without thyromegaly, and there is a
small 1-cm node below
the right ear. Otherwise unremarkable for lymphadenopathy.
LUNGS: Lungs are clear without wheezes or rales.
BREASTS: Breasts are soft, nontender. No masses or discharge.

HEART: Regular rate and rhythm. Normal S1, S2,9 with a 1/6 systolic ejection
murmur best heard at the
base.
ABDOMEN: Abdomen is soft, nontender. Active bowel sounds. Without masses or
hepatosplenomegaly
and somewhat tender over the suprapubic region.
EXTREMITIES: Examination of the extremities reveals no cyanosis, clubbing, or
edema. Peripheral
pulses are intact.
NEUROLOGIC:10 Cranial nerves 2-12 intact. Reflexes 2+ and symmetric bilaterally
with plantar flexion.
LABORATORY11 DATA ON ADMISSION

Urinalysis: Specific gravity was 1.022.12 The pH was 6.0. There were13 a large
amount of ketones.
Urobilinogen was 2-4 mg. There were 2 WBCs, there was less than 1 RBC, and there
were a few bacteria.
Urine pregnancy test was negative. Sodium was 137, potassium 3.8, chloride 99,
bicarbonate14 22. CBC:
Hemoglobin was 13.0, hematocrit 40.2, and white count was 970015 with 67 segs, 12
bands, 15 lymphs,
and 6 monos. Platelets were 219,000.16 Chest x-ray obtained showed no active
pulmonary disease.
ASSESSMENT17
1. Endometriosis.
2. Vaginal discharge.
3. Acute dehydration, 3-5%, secondary to viral syndrome.
4. Partially treated urinary tract infection. Rule out pyelonephritis.
PLAN
IV hydration. To continue the Monistat vaginal suppositories. Begin the patient on
Mandol 1 g IV q.8
hours.18 Follow with CBC and electrolytes19 in the morning. A gynecological
consult will be obtained,
and the patient is to have clear liquids as tolerated, Tigan p.r.n. nausea, and
Tylenol for fever scheduled
q.4 hours.20
4025 characters
1 Alternative: 102 to 103 degrees.

3 Edit encouraged patient to patient was encouraged because as originally
dictated, encouraged had no subject.
parentheses. Edit an to a for proper usage.
8 Edit in the recumbent to recumbent for proper syntax and parallel construction.
11 Expand unacceptable brief forms in headings.
12 The dictated �ten twenty-two� specific gravity is always written 1 followed by
a decimal and 3 more numbers.
13 Change was to were for subject-verb agreement (�amount of ketones� is plural).
14 Expand the unacceptable brief form �bicarb� to bicarbonate.
16 Express the number in full.
17 Number diagnoses when more than one diagnosis is listed.
19 Expand the unacceptable brief form �lytes� to electrolytes.

ADMISSION DIAGNOSIS
1. Term intrauterine pregnancy.

2. Active labor.
3. Unknown glucose tolerance testing.
4. Smoker.
Patient is a 21-year-old primigravida. Her last menstrual period (LMP)1 is April
17 with a 13-day
discrepancy on an 18-week ultrasound. By her LMP, her estimated date of
confinement is January 24. She
has had an uncomplicated pregnancy to date with an increase in contractions
throughout the day and
cervical change from 1 to 4 cm. She experienced artificial rupture of membranes
with clear fluid. She
reports no vaginal bleeding and active fetal movement.
GYNECOLOGIC HISTORY
No abnormal Paps or sexually transmitted diseases (STDs).3
ALLERGIES
She has no known drug allergies.
CURRENT MEDICATIONS
Prenatal vitamins only.
PAST MEDICAL AND SURGICAL HISTORY

Negative.
FAMILY HISTORY
Negative.
SOCIAL HISTORY
Smokes a half-pack a day. No alcohol or drugs.
VITAL SIGNS: Temperature 98, blood pressure 105/60, pulse 100. Fetal heart tones
140 with moderate
variability in accelerations. No decelerations. Contractions every 2 to 3 minutes.
GENERAL: She is comfortable with her epidural, alert and oriented.

CARDIOVASCULAR: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft with an estimated fetal weight of 3500 g. Cervix is 7 cm, complete,
and 0 station,
vertex, with clear fluid. Intrauterine pressure catheter (IUPC)5 was placed.
EXTREMITIES: She had 1+ lower extremity edema. No calf tenderness.

6
LABORATORYO positive, antibody negative. Serology negative. Rubella immune.

Hepatitis negative. Pap negative. GC
and chlamydia negative. Glucola test,7 the patient reports as normal; however,
there is no record in the
chart or on the computer. Today a white count is 20. Hemoglobin 13.8 and platelets
313,000.8
PLAN
Patient has a term intrauterine pregnancy in active labor with progression after 2
units of Pitocin for
protracted active phase. She has an adequate pelvis. She has an unknown glucose
tolerance screen. We
will check a fingerstick blood sugar. We encouraged smoking cessation to her and
her partner, and she
desires breast feeding.
2157 characters
1 Expand an abbreviation on first use and place the abbreviation in parentheses.

3 Expand an abbreviation on first use and place the abbreviation in parentheses.
5 Expand an abbreviation on first use and place the abbreviation in parentheses
7 Insert test. The Glucola is given to the patient to drink for the glucose
tolerance test.
8 Transcribe value in full.

This patient is a 39-year-old married white gravida 2, para 2-0-0-2, who

menstruates on a regular monthly
basis. She has had 2 normal vaginal births. Children are aged 18 and 16. She has
been followed for 2
years with myomata uteri that have been growing, and recently the patient has
developed a slight sense of
urge incontinence. It is felt that definitive therapy is warranted. Risks,
benefits, and alternatives to
hysterectomy have been fully explained. The patient seems to be cognizant of same
and wishes to pursue
this course.

The patient had a laparoscopic tubal cautery many years ago. She has no major
medical problems.
MEDICATIONS1
She is on no medications.
ALLERGIES
She denies drug allergies.
SOCIAL HISTORY
The patient is an administrator. She does not smoke, and she drinks social
quantities of alcohol.
FAMILY HISTORY
Family history is positive for hypertension, diabetes, and arteriosclerosis.
REVIEW OF SYSTEMS
The patient does perform self-breast examinations.
NECK: There are no neck masses.
CHEST: The chest is clear.
HEART: There is a normal S1, S2.3
BREASTS: The breasts are without mass or lesion.
ABDOMEN: The abdomen is slightly rotund.
PELVIC AND RECTAL: The vulva is normal. The vagina is normal. The cervix is
without lesion, and a
Pap smear was obtained and is pending. The uterus is presently4 approximately 13
weeks in size,
irregular, with firm nodular excrescences consistent with myomata uteri. There are
no adnexal masses.
Rectal exam is confirmatory. There is no overt evidence of urine stress
incontinence.

LABORATORY DATA5
An IVP was negative save for the pelvic mass. A urine culture was negative. A 2-
hour postprandial
glucose screen was 93 and also negative. A urinalysis was unremarkable.
IMPRESSION
Symptomatic and enlarging myomata uteri.
PLAN
Total abdominal hysterectomy and6 possible bilateral salpingo-oophorectomy on a
same-day surgery
basis.
1961 characters

2 Expand brief forms in headings. Subheadings are added for consistency in format.

4 The dictator says �presently now.� Delete either presently or now.
5 Paragraph and heading added.
6 Insert and because there are only 2 items, not a series.

ADMITTING DIAGNOSIS
Mild to moderate dysplasia of the endocervix.1
FINAL DIAGNOSIS
1. Severe dysplasia of the cervix.

2. Patient does have cholelithiasis.
3. Atrophic endometrium.
4. Normal appendix.
OPERATIONS
1. Total abdominal hysterectomy.

2. Bilateral salpingo-oophorectomy.
3. Incidental appendectomy.
Improved.
HISTORY
This 70-year-old gravida 4, para 3, ab 1 had her menopause at the age of 50. Her
chief complaint is mild
dysplasia on a Pap smear in July as well as December. The patient then had
biopsies of her cervix in my
office in January, which were normal. This was repeated on March 1, and
endocervical curettage revealed
mild to moderate dysplasia of the endocervix. The patient is presently being
admitted for a total
abdominal hysterectomy, bilateral salpingo-oophorectomy, and incidental
appendectomy.
PAST HISTORY
Allergies: None.
Illnesses: None.
Surgery: Left breast biopsy which was benign. She had cervical biopsies in my
office in January as well
as March.
REVIEW OF SYSTEMS
See chart.
Physical exam essentially within normal limits. Pelvic exam: Bartholin�s,
urethral, and Skene�s (BUS)2
negative. Introitus parous. External genitalia negative. Vagina was parous, pale,
with no rugae. The cervix
revealed no posterior fornices. The uterus and adnexa were not palpable.
IMPRESSION ON ADMISSION
Mild to moderate dysplasia of the endocervix.
On the day of admission, patient was taken to the operating room where she had a
total abdominal
hysterectomy, bilateral salpingo-oophorectomy, and incidental appendectomy. It was
also noted she had 1
stone in her gallbladder. Postoperatively, on her 1st hospital day, she spiked a
temperature of 101.3�.3 The
lungs were clear, and the abdomen was soft. Catheterized4 urinalysis was normal.
It was felt that she had
postoperative pelvic cuff cellulitis, and she was started on IV ampicillin.
Thereafter she became afebrile,
began eating, ambulating, and voiding, and she was discharged on her 3rd
postoperative day in good
condition on Tylenol with Codeine as well as ampicillin and will be seen in my
office in 1 week.
LABORATORY DATA
Pathology report revealed severe dysplasia of the cervix. SMA-16: All values
within normal limits. No
growth on culture and sensitivity of a catheterized5 urine specimen. Admitting
urinalysis normal. Patient
had O positive, antibody screen-negative blood. PTT normal. Postop catheterized6
urinalysis: 1+ bacteria
with 2-5 red blood cells, 6-10 white blood cells. Hemoglobins of 13 and 12 g with
white counts of 40007
and 9000. Chest film revealed no acute pulmonary disease. EKG was basically within
normal limits.
DISPOSITION
Patient will be discharged and seen in our office in 1 week.
2691 characters
1 Omit the dictated number 1. It is preferable not to number the diagnosis when
there is only one.
parentheses.
3 Alternative: 101.3 degrees.
7 Alternative: 4 thousand.

ADMITTING DIAGNOSIS
1.
A 41-5/7-week multipara admitted for active rupture of membranes, with possible
medical
induction of labor for postmaturity.
2.
Increased maternal age.
DISCHARGE DIAGNOSES
1.
Status post normal spontaneous vaginal delivery of viable term male infant.
2.
Increased maternal age.
3.
Second-degree midline episiotomy�repaired.
ADMITTING HISTORY AND PHYSICAL FINDINGS
The patient is a 40-year-old gravida 3, now para 3, last menstrual period (LMP)1
July 122 and expected
date of confinement (EDC)3 of April 16, who was admitted at 41-5/7 weeks�
gestation by good dates
because of postmaturity. She was to undergo active rupture of membranes and, if
necessary, medical
induction of labor. Her prenatal course had been unremarkable except for increased
maternal age and
occasional premature beats auscultated on exam in the office. Prenatal lab work
had been completely
within normal limits. Blood type was O positive.
PHYSICAL EXAMINATION4 ON ADMISSION

Blood pressure 140/80. Otherwise the vital signs were normal. Examination was
completely
unremarkable except for 2+ pedal edema and cervix being dilated to 2-3 cm, 50%
effaced, and -3 station.
Deep tendon reflexes (DTRs)5 were 2/4 and symmetric at the knees. There was no
evidence of any clonus
whatsoever.
HOSPITAL COURSE
The patient underwent active rupture of membranes with leaking of clear amniotic
fluid. Internal scalp
monitor was applied. Fetal heart tones showed good variability and were within
normal range. Patient
began having spontaneous contractions subsequently and progressed rapidly through
active phase of labor
and delivered in the home birthing room a viable term male infant, Apgars of 9 and
9 over a 2nd degree
midline episiotomy that was performed under 1% Xylocaine local anesthetic. The
episiotomy was
repaired with 2-0 chromic in layers. Placenta was delivered spontaneously, intact,
with 3-vessel cord.
Estimated blood loss was 200 mL.6 The mom and infant had no immediate postpartum
complications.
The patient�s postpartum course was completely unremarkable. Postpartum day #1
hematocrit was 37.5.
Her urinalysis showed no proteinuria. There were a few red blood cells present but
0-1 white cells.
DISPOSITION
Discharged home. Follow up in the office in 6 weeks, sooner if problems. The
patient will continue her
prenatal vitamins.
2334 characters

1 Expand abbreviation on first use and place the abbreviation within parentheses.
2 It is preferable to spell out dates used in the body of a report, writing out
the name of the month and using four
digits for the year (if known).
6 The dictated �cc� is on the list of dangerous abbreviations and should be edited
to mL (milliliters).

FINAL DIAGNOSIS1
Recurrent menorrhagia unresponsive to hormonal therapy.
OPERATIONS PERFORMED
Total abdominal hysterectomy, bilateral salpingo-oophorectomy.
BRIEF HISTORY AND HOSPITAL COURSE

This 45-year-old white female, gravida 3, para 2, ab 1, was followed in my office
for the past several
months with a history of recurrent menorrhagia. Patient had been placed initially
on hormones. At some
point dilatation and curettage (D&C)2 was then performed. However, the patient
continued to bleed
almost on a daily basis. At that point options were discussed with the patient.
She opted for a total
abdominal hysterectomy and bilateral salpingo-oophorectomy. She understood the
procedure as well as
its possible complications. Thus, the following day after admission to the
hospital, she was taken to the
operating room where, under general anesthesia, a total abdominal hysterectomy and
bilateral salpingooophorectomy
were3 performed without difficulty. Postoperatively the patient did well without
any
complications and was discharged on the 4th postoperative day. By that point the
patient had moved her
bowels and was urinating well. Wound care instructions were given to the patient
as well as prescriptions
for Tylox q.4 h.4 p.r.n. #15. She was to come to the office in 3 weeks� time for a
followup visit. The final
pathology report demonstrated multiple leiomyomas.
1379 characters
1 Edit diagnoses to diagnosis because there is only 1 listed.

3 Edit was to were for subject-verb agreement (�hysterectomy and . . . salpingo-
oophorectomy were�).
4 Express the phrase fully for clarity.

ORTHOPEDICS DICTATION #1
OFFICE NOTE (0:30)
The patient is a 51-year-old diabetic female who has a 9-month history of an ulcer
underneath her right
calcaneus which has been nonresponsive to previous debridement and continued
conservative treatment.
X-rays show plantar periosteal reaction, and a bone scan shows increased activity
in the inferior
calcaneus. MRI is consistent with osteomyelitis of the distal calcaneus.
DIAGNOSIS
Osteomyelitis, right calcaneus, with diabetic foot ulcer.
460 characters

OFFICE NOTE (1:00)
A 33-year-old white male who sustained a traumatic injury to his left shoulder. He
had stabilization of his
acromioclavicular (AC)1 joint over a year and a half ago, and he has had
persistent pain in his left
shoulder. He was evaluated preoperatively and found to have evidence of biceps
tendinitis.
A repeat physical exam without guarding showed marked anterior glenohumeral

instability. The patient
was subsequently planned for a diagnostic arthroscopy and left anterior-inferior
capsular shift.
DIAGNOSIS
1. Left shoulder instability.

2. Rule out biceps tendinitis.
583 characters
Expand abbreviation on first use and place abbreviation within parentheses.

OFFICE NOTE (0:30)
Still has some pain in the left heel insertion area. Again no lumps or masses felt
and no increased
temperature. No nodularity. I think he should just continue his therapy. He can
start to maybe do some
bike riding and should give it some more time. He did have a negative x-ray the
last time. I will see him
again in 2 months.
345 characters

OFFICE NOTE (1:00)
SUBJECTIVE
Patient is here for followup to discuss results of bone scan, which are normal.
She has shin splints as well
as an Achilles tendon bursitis and has been on Clinoril b.i.d. She says there is
some improvement in the
pain of her heels, but the shin splints are still quite painful. She is continuing
to do exercises but not
having relief. She also has some allergic rhinitis symptoms.
OBJECTIVE
Physical exam not done today.
ASSESSMENT
Shin splints and Achilles tendon bursitis bilaterally.
PLAN
Will increase Clinoril to 200 mg p.o. b.i.d. Patient is to continue doing
exercises. Will refer the patient to
physical therapy for further evaluation and treatment.
681 characters

OFFICE NOTE (1:00)
This 30-year-old male has been followed by me. He is a right below-the-knee (BK)1
amputee. He has
been having pain in the right side of his knee on the lateral aspect. He did have
resection of his peroneal
nerve approximately 6 weeks ago. The wound has healed, all but one small area. It
was felt that he may
have some bursitis or tendinitis on the lateral aspect of the femoral condyle. A
few injections have been
done which have helped somewhat, but he still has an area of persistent
discomfort. X-ray was obtained
which is negative. The lateral and posterior aspects2 of the knee were3 again
injected with Xylocaine and
Depo-Medrol. If this does not help completely, we should start him back on some
physical therapy.
736 characters

2 Edit aspect to plural aspects for accuracy.
3 Edit was to were for subject-verb agreement (�aspects . . . were�).

OFFICE NOTE (4:00)
The patient was last seen by me in the office, and she was instructed to continue
on her physical therapy
(PT).1 She was felt to be still totally disabled until her next recheck. I felt
the patient was approaching a
permanent and stationary status and could be considered for involvement in a rehab
evaluation and rehab
program in the near future.
The patient called, and she wanted to know if I wanted to have her to come in in
the next week for a
cortisone shot. She indicated that she saw a medical doctor (MD)2 apparently for
an independent
orthopedic evaluation, and he allegedly said there was a �soft spot on the
cartilage,� and that her
�overweight� and �knock knee� work against her. The patient indicated she sits in
class 2 hours at a time,
and it makes her knee hurt when she sits there. On Monday3 night her knee was
okay, but on Tuesday the
knee was popping and had sharp pains and was real sore. On Wednesday morning the
sharp pain was
gone, but the knee was still sore and swollen. She said she cannot4 sit Indian
fashion anymore, meaning
cross-legged.
The physical therapy progress report stated, �. . . has been doing very well in
therapy until this last
weekend. During this past weekend she had several episodes of popping with her
knee, and pain resulted
from these popping sensations. We have worked her quadriceps very good in therapy
and appear to be
strengthening nicely. Had very little discomfort with her gym program these past 2
weeks.�
The orthopedic examination revealed the circumferences of the thighs measured with
the knees flexed to
a right angle from the popliteal flexion crease to the suprapatellar area, right
over left, were 16-3/4 inches5
over 16-3/4 inches. The circumferences of the legs at the level of maximum girth,
right over left, were 163/
4 inches over 16-5/8 inches. The knee and ankle jerks were brisk and equal
bilaterally. There was slight
patellar crepitus on the right with active nonweightbearing flexion and extension
movements of the right
knee, whereas there was no similar crepitation on the left. There was no obvious
knee swelling on the left
compared to the right. The left knee extended fully to 180�6 and flexed through a
range of 130�, or 40�
greater than a right angle. The left knee was stable at 180� of extension, and
there was slight collateral
laxity at 160� of extension, and there was a negative drawer sign at 90� of
flexion on the left. With testing
for collateral laxity at 160� of extension, the patient complained of some hurting
at the anteromedial joint
line of the left knee. Better bulk at the left vastus medialis obliquus muscle
area compared with the right
vastus medialis obliquus area. The patient was slightly tender via the reflex
hammer strike at the left
infrapatellar tendon. Pinprick was slightly increased over the anteromedial aspect
of the right knee
compared to the left knee. Therefore pinprick was decreased over the anteromedial
aspect of the left knee
compared to the right one. Patient�s patella was mobile bilaterally, right equals
left, as tested with the
knees extended and the quadriceps mechanism relaxed, with the patellae being
manipulated by the
examiner in a proximal, distal, and mediolateral direction. Therefore I felt that
no lateral patellar release
was needed. It hurt the patient to mobilize the left patella passively, where she
had no symptoms with
right patellar passive mobilization. There was a slight patellar snap on the right
without complaint. She
was able to perform a half-squat before she had any symptoms of discomfort in the
left knee.

RECOMMENDATIONS AND/OR TREATMENT
The patient was to continue on her quadriceps program. She was to continue on an
off-work status and be
rechecked by me in 1 month.
3760 characters
1 Expand an abbreviation on first use and place abbreviation within parentheses.

Change an to a before a consonant
sound.
3 On the job, you would change Monday, Tuesday, and Wednesday to a date. When
referring to a day in a report, use
the day�s name and the date. Avoid terms such as last Monday or next Wednesday.
5 Do not use the symbol for inches, except in tables as a spacesaving device.
6 In expressing angles, write out degrees or use degree sign (�).

OFFICE NOTE (0:30)
A 45-year-old male who complains of prepatellar pain throughout the left knee for
over a year. He denies
mechanical symptoms or effusions but does report increased swelling over the
kneecap. He is unable to
kneel without pain. X-rays were obtained and demonstrate no evidence of fracture
or dislocation, but a
large prepatellar bursa is visible.
363 characters

OFFICE NOTE (0:30)
A 38-year-old female who has a history of right knee pain for the last 5 months.
She reports that she
sustained an injury while camping, and this pain has been present since then. She
locates the pain to the
medial aspect of her knee and says that it occasionally radiates to the thigh. She
reports that her pain is
not improved with anti-inflammatory medication or strengthening exercises for her
vastus medialis
obliquus.
On physical exam she did not have a true McMurray sign, but an MRI obtained shows
questionable
posterior horn of the medial meniscus tear. She is scheduled for diagnostic
arthroscopy and possible
medial meniscectomy.
658 characters

BRIEF HISTORY
This patient is a 24-year-old black gentleman who was transferred after running
from the police. Patient
sustained an open grade 2 femur fracture, closed head injury, chest trauma, and a
closed fracturedislocation
of his left elbow. In the trauma bay the patient was stabilized by the general
surgery trauma
team and had a closed reduction done of his left elbow, and it was splinted. The
right femur was placed to
traction. Patient was sent to the CT scanner and consented for surgery.
524 characters

The patient is a 15-year-old white male who is admitted for conservative

management of chronic neck
and low back pain. This occurred when he was cross-body blocked while playing
soccer. He was hit from
the blind side, knocked down while he was bringing the ball up the field and
dribbling. The patient stated
that he was dazed. It had taken him almost 10 minutes before he could get up to
his feet. The breath had
been knocked out of him. Multiple x-rays were taken and were all within normal
limits. Neurologic
exams as an outpatient were performed, and no neurologic deficits could be found.
Because of the chronic
pain, the patient was admitted for intensive physical therapy, after failing
outpatient therapy, and cervical
traction. During this period of time the patient continued to improve, and his
symptomatology was
decreased. He was discharged after receiving maximum hospital benefit, to be seen
as an outpatient in
approximately 2 weeks. During his course of his hospitalization, patient was seen
for an atopic dermatitis
for which he received treatment.
DISCHARGE DIAGNOSIS
1. Chronic cervical sprain.

2. Chronic lumbar sprain.
3. Contusion to the right shoulder.
4. Atopic dermatitis.
1223 characters
1
Edit is to was for proper verb tense.

The patient is a 26-year-old male who sustained a right distal humerus oblique
fracture while throwing a
football. There was significant displacement. The decision was made to proceed
with open reductioninternal
fixation. The risks versus benefits of the procedure were discussed with the
patient, and he
wished to proceed as planned.
360 characters

A 39-year-old white female underwentopen ACL reconstructions more than 10 years

ago. She was
subsequently seen for lateral joint line pain and was planned for diagnostic
arthroscopy and possible
debridement of lateral meniscal tear.
259 characters
1
Edit undergone to underwent for correct verb tense.

This is a healthy 44-year-old female who has had ongoing pain since an accident
several years ago. She
has been unable to return to all of her daily normal activities which have
included extensive exercising.
Because of the ongoing pain and problems that she has had, she has had several
surgeries to try to help
her. The last of these demonstrated a large trochlear lesion and a small meniscal
tear laterally.
Meniscectomy and debridement were performed, but it was felt that more extensive
work including
chondral work would be appropriate. She was referred for that reason. After the
risks, benefits, and
alternatives as well as the possibility of further peroneal problems which have
been caused by previous
surgeries, she electively decided to proceed.
783 characters
The dictator corrects himself without saying �correction.�

2
The verb felt has no subject; it was is inserted for correct grammar.

An 81-year-old white female who had a nondisplaced femoral neck fracture treated
at an outside
institution. She subsequently underwent a cannulated hip pinning and was doing
well until she developed
localized pain over her trochanter. Postoperative films a number of months after
the procedure revealed a
well-healed femoral neck fracture with some femoral neck collapse and protrusion
of her cannulated hip
pins. She is planned for removal of cannulated hip pins.
489 characters
Insert an to avoid beginning the sentence with a number.

BRIEF HISTORY
The patient is a 36-year-old white male, status post tree falling on left lower
extremity. Patient was
initially brought to the operating room at which time a fasciotomy was done on the
left tibia. Patient
underwent irrigation and debridement and partial wound closure. Patient had the
medial fasciotomy
wound closed, and the lateral wound was partially closed. Patient returns to
surgery today for irrigation
and debridement of the lateral fasciotomy wound and attempted closure.
518 characters

A 72-year-old patient admitted to the hospital because of persistent, severe left

sciatica. The patient had
had onset some 2 weeks prior, and conservative measures have not helped at all,
and she was at a point
where she could not ambulate because the leg tended to collapse because of pain.
The initial impression was left sciatica, probably secondary to a herniated disk,
chronic obstructive
pulmonary disease, arterial insufficiency of the lower extremities, and status
post right mastectomy for
adenocarcinoma.
LABORATORY DATA
The CT scan of the lumbosacral area showed generalized marked bulging of the disk
at L3 and L41 with
evidence of spinal stenosis and degenerative changes of the facet joints at that
level. Chest x-ray: The
diaphragms were flat, consistent with chronic obstructive pulmonary disease, and
the chest was somewhat
kyphotic. There were no infiltrates. EKG: Considered normal.
HOSPITAL COURSE
Patient was placed initially on Demerol for relief of pain. She was on heating pad
and muscle relaxants.
Gradually over a several-day period of time, there was slight improvement,
although with any attempt at
ambulation, she continued with pain. She was started on a physical therapy regime2
including ultrasound
and Hubbard tub. Epidural steroid injection was accomplished. This was done under
intravenous sedation,
and a good block was obtained. The patient was at least 50%, perhaps as much as
60% improved, was
able to ambulate, and was discharged to have her follow up with regard3 to
additional epidural steroid
injections.
At time of discharge her medications included digoxin 0.25 mg each a.m., Dilantin
300 mg at bedtime,
albuterol inhaler. She will be given a prescription also for Percodan in small
amount.
FINAL DIAGNOSES
1. Herniated lumbar disk at the area of L3-L4.

2. Spinal stenosis.
3. Left sciatica due to the herniated disk.
1908 characters
1 The dictator says �L3 and 4.�

2 Alternative: regimen.
3 Edit �with regards to� to correct phrase with regard to.
HISTORYThe patient is a 54-year-old male with a history of hypertension, diabetes,

and an atrophic left lower
extremity. On the night prior to admission, he suffered a fall and sustained a
fracture of his left hip. He is
admitted at this time for stabilization and repair of his hip fracture.
HOSPITAL COURSE
Subsequent to admission the patient was seen, and arrangements were made for
repair of his hip fracture.
He was also seen in consultation because of a history of alcohol abuse. The normal
admission laboratory
studies included EKG, a hemogram, and chemistry profile. The patient eventually
was taken to the
operating room, and an open reduction and internal compression screw fixation of
the hip was
accomplished. The patient�s convalescence was uncomplicated, and he was eventually
discharged home
symptomatically improved and in stable condition on no specific activity
restrictions other than the
avoidance of alcohol.
FINAL DIAGNOSIS
1. Acute hip fracture.

2. Type 2 diabetes.
3. Hypertension.
4. History of chronic bronchitis.
5. History of alcohol abuse.
1087 characters

This 32-year-old female first noted back pain after she leaned over to pick
something up. She improved,
but in February of this year, she again developed back pain and then pain in the
left hip. On occasion she
had numbness and fleeting pain in the left thigh as well. Conservative treatment
gave no relief. She was
referred after an MR scan of the lumbar spine revealed what appeared to be a
herniated disk at L5-S1 on
the left.
A myelogram and postmyelogram CT scan on this admission confirmed the presence of

a disk herniation
at that level. The situation was discussed with her and microdiskectomy
recommended. She agreed to
this. She was taken to the operating room where microdiskectomy at L5-S1 on the
left was carried out.
Postoperatively she did well, getting excellent relief of her hip and thigh pain
and continued to improve.
She was discharged on the 2nd postoperative day to be followed in our office.
941 characters

OFFICE NOTE (1:00)
A 58-year-old white male with persistent pain in the neck, left shoulder, and arm.
He had clinical
findings suggestive of a C6 radiculopathy. He was in for neurodiagnostic
evaluation and did have a
cervical myelogram and enhanced CT scan, which confirmed a bone spur
(posterolateral osteophyte) at
C5-6 on the left. He was originally scheduled for cervical laminectomy and
foraminotomy of the nerve
root but cancelled this surgery and requested a second opinion. He does have
symptoms suggestive of a
C6 radiculopathy and possibly, in addition, ulnar nerve involvement at the elbow.
We have elected to try
a course of intensive physical therapy to include ultrasound, light massage, and
intermittent traction 2 or 3
days a week for several weeks. Should this not relieve his pain, should his pain
be persistent, I would like
to see him back in the office for reevaluation and consideration then for
admission to the hospital and
surgical intervention.
970 characters
1
Add A
to avoid beginning the sentence with a number.

A 29-year-old right-hand-dominant male who works as a police officer. He sustained

a gunshot wound to
the right forearm. He was initially stabilized at the hospital and transferred for
further evaluation of
possible neurovascular compromise. A1 2+ radial pulse and 1+ ulnar pulse. Mild
swelling of the forearm
and humerus. Sensation intact over the median, radial, and ulnar nerve
distributions. Radiographs
demonstrated a comminuted ulnar shaft fracture with extension into the olecranon
and metallic fragments
in the intra-articular space of the elbow. A consent was signed per his wife due
to the patient�s injury.
641 characters
1
Add A
to avoid beginning the sentence with a number.

HISTORY
An 18-year-old male who suffered a snowboarding injury approximately 2 weeks ago.
He had immediate
pain and deformity about his left shoulder. He has had a visible and palpable
prominence about his left
shoulder. Pain with range of motion of his shoulder. On exam he was found to have
a palpable clavicle
fracture. He had a prominent bone spike at the midshaft. This was nonreducible. He
had approximately 1
inch of shortening of his left clavicle compared to the right side. He had
sensation intact to light touch
over the median, radial, ulnar, and axillary nerve distributions. Motor was 5/5
throughout. Radial pulse
2+. Radiographs demonstrated a displaced clavicle fracture with a comminuted piece
at 90�1 to the shaft.
Risks of operative intervention include infection, bleeding, pain, numbness,
tingling, weakness, nonunion,
malunion, shoulder stiffness, need for further surgery, failure of fixation,
injury to nerves causing
numbness or weakness across the chest or into the arm, injury to blood vessels
causing damage to the
arteries going to the arm or chest, injury to a lung, as well as other possible
complications. Patient stated
he understood and wished to proceed with surgery.
1230 characters
1
In expressing angles, write out degrees or use degree sign (�).

CONSULTATION (1:00)
HISTORY1
This 81-year-old female was admitted 2 days ago, lost her balance, fell, injured
her left hip area. She has
had pain and2 difficulty walking because of her symptoms. She did have a
hemiarthroplasty, bipolar type,
of the left hip. She has done well since this surgery.
Examination revealed an alert 81-year-old female. Examination of the left hip
revealed very satisfactory
range of motion with no particular discomfort. On palpation there is some
tenderness in the left inguinal
area. There is no unusual swelling or discoloration.
X-RAYS
AP of the pelvis and3 lateral views of the left hip revealed moderately severe
osteoporosis. There is no
discernible fracture. There could be a fracture involving the ischial or pubic
rami which is4 not visible at
the present time. There is some indication that she has had an old fracture of the
left pubic ramus.
No particular precaution needs to be taken. She should be allowed to ambulate

using a walker or a cane in
the right hand. I will not follow up unless I am further called.
1068 characters

4 The antecedent of which is fracture, not rami, so the singular verb is
is correct. The ischial and pubic rami would
be visible on the films.

A1 36-year-old2 female admitted for surgery of her left ankle. This patient had
fallen at home and
sustained an injury of her left ankle, a diagnosis of posterior malleolar-lateral
malleolar fracture with
minimal widening of the ankle mortise made at that time. It was elected that a
short leg, well-molded cast
be applied in order to see if this would maintain a relatively nondisplaced
fracture with, as mentioned
above, minimal widening of the ankle mortise. She was seen in the office at which
time repeat x-rays of
the ankle revealed unsatisfactory maintenance of the fracture fragments with cast
support. The ankle
mortise was widening, and there was significant displacement of the posterior as
well as lateral malleolar
fragments.
Admitted and taken to surgery, where an open reduction and3 plate fixation of the
lateral malleolus was4
carried out as well as internal fixation of the posterior malleolus. A transfixion
screw was placed through
the fibula into the tibia. The wound was inspected prior to discharge and found to
be healing well. A short
leg cast was applied. She is not to bear weight on the left lower extremity.
Because of patient�s poor
balance and weakness of her right lower extremity, it was decided that she just
confine herself to bed and
wheelchair type of existence. She will be seen again in the office in 6 weeks.
Take oral temperatures 3
times a day, and if elevated over 99, she is to call me. Tylox prescribed for
pain.
1494 characters
1 Add an article to avoid beginning the sentence with a number.

2 It�s uncertain whether the patient is 36 or 56. On the job the transcriptionist
would verify the patient�s age.
4 Add was to complete the verb.

OFFICE NOTE (1:30)
X-rays of the lumbar spine when finally reported showed �advanced degenerative
disk disease at
L3-5 levels, moderate advanced degenerative disease at L5-S1 level,
atherosclerosis and early aneurysmal
formation of the aorta.� X-ray of the left hip was done although the x-ray of the
right hip was ordered.
MRI of lumbar spine was reported as �lumbar scoliosis, advanced degenerative
spondylitic changes, L5
through S1, with accompanying central canal stenosis which is more pronounced at
the L3-4 and L4-5,
and accompanying moderate bilateral facet joint osteoarthritic changes at these
levels. There is conclusive
evidence for focal disk herniation by MRI imaging.� It took 4 days to get this
report back.
A TENS unit was ordered and has been a continual problem with malfunctioning. The
patient has
ambulated with aid of walker. The day of discharge the TENS unit is still not
functioning.1 The electrodes
are coming off. The patient does get relief of pain on those times that the TENS
unit does function
properly.
1034 characters
1 This physician makes several observations (delayed transcription and faulty

equipment) that may identify risk
management issues. On the job the transcriptionist would bring these complaints to
the attention of appropriate
personnel.

A 28-year-old who sustained a fall on the ice yesterday. His x-rays revealed a
fibular shaft fracture with
widened mortise consistent with a Maisonneuve-type ankle injury. He reports that
he is a very large
individual weighing 240 pounds, is not very coordinated on his crutches, and has
already fallen a couple
of times. Because of the concern over his ability to comply with weightbearing and
because of his large
size, we will plan on placing 2 syndesmotic screws for extra strength.
510 characters

PHYSICAL THERAPY PROGRESS NOTE (3:00)
DIAGNOSIS
General weakness.
SUBJECTIVE1
The patient reports that he is now feeling more confident about his ability to
function at home.
OBJECTIVE
Therapy: Therapy was on hold due to a deep vein thrombosis in the right calf.
Therapy was resumed, and
the patient has been seen b.i.d. since that time. The patient was accompanied by
the physical therapist and
occupational therapist for a home visit. The patient was resistant to a few of the
suggestions made to him
about placement of rugs as well as handholds for getting in and out of the tub as
well as getting up and
down from upholstered furniture. However, he did agree to most of the suggestions
and should carry
through with them once reaching home. The patient has 3 different sets of stairs
at home which he must
negotiate. All of these stairs are located next to doorways where the moldings are
thick enough for him to
hold onto them with one hand. Therefore the patient has available at home more
handholds for stability
than what were being practiced in therapy when he was not allowed to use the
railings. At home the
patient was noted to move the large-based quad cane in an awkward manner. He would
occasionally
switch hands so that the cane would be backward and partly in the way of his feet
as he was walking. For
this reason a standard cane will be issued rather than a large-based quad cane.
Bed Mobility: The patient is now able to roll to his right or left independently
and is independent also for
supine-to-sit transfers.
Transfers: The patient was able to complete all transfers at home independently.
Gait: The patient is able to achieve distances up to 175 feet with a standard cane
and supervision. The
large-based quad cane is no longer being used during therapy. The patient is able
to negotiate the stairs
using only a standard cane and no railings, with standby assistance.
ASSESSMENT
The patient has achieved all short-term goals with the exception of ability to
negotiate the stairs with
supervision rather than with standby assistance.
Short- and long-term goals will be the same for this week, as discharge will be
scheduled for sometime
next week.
Those remaining goals are as follows:
1. Ability to walk independently 200 feet with a standard cane.

2. Ability to negotiate stairs independently with the use of a cane.
PLAN
Will continue b.i.d. 45-minute treatment sessions as previously outlined. Patient
will be scheduled for a
community outing in order to assess his ability to function independently outside
of his home
environment.
2550 characters
1 The dictator says S, O, A, P for the headings, and in order to conserve space in
the chart, some facilities format
their SOAP notes by using section headings followed by colons, with findings
beginning on the same line.

PHYSICAL THERAPY NOTE #2 (4:00)
CURRENT MEDICAL HISTORY

This 66-year-old white female was admitted due to severe chest pain for elective
coronary catheterization.
Catheterization revealed significant occlusions. She underwent surgery for 3
grafts.

Diabetes mellitus. The patient is currently on insulin. Hypertension, laser
surgery both eyes, carpal tunnel
release, degenerative joint disease.
SOCIAL HISTORY
The patient is widowed and lives alone in a senior citizen apartment.
EVALUATION
The patient was evaluated in the department.
SUBJECTIVE
The patient states that she owns a small-based quad cane which is currently at
home. She stated that she
plans to stay with a friend for a while after leaving the hospital. Her friend�s
home has 3 steps to enter
with a railing on both sides. She has multiple complaints of pain and discomfort
due to stitches in the
right leg as well as problems with arthritis and bowels.
OBJECTIVE
Communication: The patient verbalizes much of the time and occasionally needs
redirection to the task at
hand. She is alert and able to follow simple and complex instructions well.
Observation: The patient currently guards movement of the right lower extremity
due to discomfort from
stitches.
Range of Motion: Upper extremities are within functional limits for age. Lower
extremities are also
within functional limits, although both knees lack terminal extension due to
apparent arthritic changes.
Strength: Bilateral upper extremities are 3+ to 4- at the shoulder, 4-at the
elbow, and 4- to 4 at the wrist
and hand. Right lower extremity strength grossly tested as 3- at the hip and knee
and 4- at the ankle. The
patient does not appear to be giving maximum resistance during testing of the
right lower extremity due
to discomfort from stitches and guarding. Actual strength may be greater than that
elicited during testing.
Left lower extremity is approximately 3+ at the hip, 4 at the knee, and 4 at the
ankle.
Bed Mobility: The patient needs minimal assistance to achieve a sit-to-supine
transfer, as she has
difficulty elevating her right leg to the bed. She needs verbal cues as well as
minimal assistance to roll to
her right or left side.
Balance: Sitting balance is good. Standing balance is currently fair to fair plus.
Transfers: The patient needs standby assistance to stand from her wheelchair but
needs standby to
minimal assistance when standing from lower surfaces, such as the bed.

Gait: The patient was able to walk with a walker a distance of 20 feet with
standby assistance and cues for
sequence. She tends to shuffle her right foot and is not able to correct this even
with verbal cues. Gait was
also attempted with a small-based quad cane, and the patient required standby to
minimal assistance with
the quad cane due to small balance losses.
ASSESSMENT
The patient currently has minimal functional deficits in mobility. The short-term
goals are as follows:
1. Ability to stand from the chair or bed with supervision.

2. Ability to walk with a walker independently a distance of 50 feet.
3. Ability to walk with a small-based quad cane and standby assistance 50 feet.
4. Ability to complete stairs with standby assistance.
Long-term goal is for independence in all areas of mobility. The patient may
require use of a cane or
walker in order to be independent.
PLAN
Will continue daily treatment in the department with emphasis on transfer
training, bed mobility, and gait.
3434 characters


An 81-year-old white female was admitted following left intertrochanteric fracture
secondary to a fall.
Open reduction and internal fixation of the left femur using AMBI hip screw.
During her hospitalization
in the orthopedic unit, investigations were done for dizziness, and she was found
to have 99% stenosis of
left carotid artery and was transferred to the surgical unit for left carotid
endarterectomy. She was
readmitted to the rehab unit.

Significant for hypertension, osteoporosis, hypercholesterolemia, and depression.
Status post compression
fracture of the dorsal and lumbar spine. Status post right eye cataract surgery.
History of venous
insufficiency and carotid artery atherosclerosis.
ALLERGIES
None.
SOCIAL HISTORY
She was living alone in a 1st floor apartment.
MEDICATIONS ON ADMISSION
Dyazide 1 p.o. daily, clofibrate 500 mg p.o. b.i.d., ergocalciferol 50,000 units
Tuesday and Friday, ferrous
sulfate 300 mg p.o. t.i.d., Bactrim double-strength1 1 p.o. b.i.d.
HOSPITAL COURSE
At the time of admission to the rehab unit, patient was dependent in bed mobility,
transfers, ambulation,
and activities of daily living. She was started on an intensive rehabilitation
program. She received
physical and occupational therapies. It was made clear to the patient and to the
family that unless she
started participating fully with the therapy, she would have to be discharged and
told to look for
alternative placement. In view of her behavioral problems, psychiatric consult was
also obtained, and
according to the daughter the patient had a history of depression about 30 years
ago. Psychiatric consult
was obtained and impression was that the patient probably has a personality
disorder and adjustment
disorder with early mild questionable dementia. No medications were recommended.
She had the
potential to improve, and with much prodding the patient started participating in
therapies. Now at the
time of discharge she is independent in bed mobility. She transfers with standby,
and she requires standby
for lower extremities. She can put on and off her socks and shoes independently
using adaptive
equipment. She has been ambulating in the therapy department about 70 feet twice
using a walker with
40-pound weightbearing restrictions on the left lower extremity with standby
assist. She has shown good
progress and has been more cooperative. In view of her improved participation and
progress with therapy,
it was felt that she would be ready for discharge home provided the weightbearing
status was changed to
weightbearing as tolerated. I did not feel safe in sending her home with the
weightbearing restrictions on
the left lower extremity. Her progress was shared with her daughter. I also
conveyed to her that home

discharge would not be safe in view of patient�s inability to follow through with
the weightbearing
restrictions. She would not be safe alone and so she should be discharged to a
nursing home for a period
of about 4-6 weeks.
The patient was started on Bactrim while in the surgical unit, most probably for
urinary tract infection.
She was very nauseated and had several small amounts of vomitus and was getting so
preoccupied with
the nausea and vomiting that she was unable to participate in therapies, so
Bactrim was discontinued. At
this time she was started on Carafate for nausea.
Her systolic blood pressures while in the hospital ranged from 100 to 130 with
diastolics in the 50 to 70
range. The patient was losing potassium several times, and this was supplemented
on several occasions.
At the same time she was getting very dehydrated while on the Dyazide, and I felt
that she would do well
even without Dyazide. This was discontinued, and her blood pressures have remained
stable. Her lungs
have stayed clear. There has been no edema of the feet and no other signs or
symptoms. Her repeat
potassium levels were 4.4. She was started on self-medication program, but the
participation was very
poor. I have discussed with the daughter about the discontinuation of the Dyazide,
and she should be
followed up in the future by her private doctor to see if she would need any
Dyazide. A psychological
evaluation was obtained to improve patient participation.
LABORATORY DATA
Serum electrolytes were within normal limits. Urinalysis revealed WBC over 100,
many bacteria. Culture
revealed greater than 100,000 Escherichia coli.2
MEDICATIONS ON DISCHARGE
Ergocalciferol 50,000 units every3 Tuesday and Friday, clofibrate 500 mg p.o.
b.i.d., ferrous sulfate 300
mg p.o. t.i.d., Carafate 1 g orally half an hour before meals, ampicillin 500 mg
p.o. q.6 hours4 until
October 5.
Repeat urinalysis and culture and sensitivity to be done.5
DISCHARGE DIAGNOSIS
1.
Status post open reduction and internal fixation, left femur, secondary to left
intertrochanteric
fracture.
2.
Status post left carotid endarterectomy.
At the time of discharge she is medically stable. Lungs are clear. There is no
edema of feet. Homans sign
is negative. Blood pressure (BP)6 has remained stable. The patient should be
followed up for medical
followup following discharge from rehab unit. Discharge diet regular. Right now
she is on 40 pounds
partial weightbearing on the left lower extremity. The patient should receive
physical therapy for
ambulation training with 40 pounds weightbearing on left lower extremity. Patient
should be encouraged
to be independent in transfers, bed mobility, bathing and dressing, and she has
been ambulating in the
physical therapy department about 70 feet twice with standby and verbal cues using
a walker with 40
pounds weightbearing on left lower extremity, and she should be encouraged to do
that. She should also
be encouraged to be on self-medication7 program.
5766 characters

1 Alternative: Brand name Bactrim DS (which means double-strength).
2 Transcribe genus and species in full on first use.
3 Edit q. to every; q. Tuesday is not a standard form.
5 This sentence does not belong with the paragraph on medications, as dictated,
and is thus placed in a separate
paragraph. On the job the transcriptionist would flag it to the dictator�s
attention. Alternative: Move the sentence to
the Laboratory Data paragraph or the final paragraph on discharge plans.
6 Expand an abbreviation on its first use and place abbreviation in parentheses.

A 56-year-old who was admitted with a long history of low back pain and leg pain.
He has now been
suffering severe right thigh pain. His MRI and myelogram and CT scan were
compatible with a herniated
disk at L3-4 on the right side. He was taken to surgery, undergoing a
microdiskectomy at L3-4 on the
right. He seemed to have prompt improvement in his leg pain and was discharged on
the 2nd
postoperative day to return to clinic in 2 weeks for followup.
478 characters
Insert an article to avoid beginning the sentence with a number.

The patient is an 8-year-old white male who was admitted through the emergency
room with a closed
comminuted fracture of midshaft of left femur. Apparently the accident occurred
when he collided while
riding a bicycle with his brother who was also on a bicycle. His brother was 6
years of age. The patient
had a long butterfly fragment of the left femur. The fracture was closed. He did
not have any head or
other neurologic injuries. The patient was initially placed in Russell�s1
traction. Neurovascular status of
that extremity was intact. Multiple x-rays were then obtained, and he was followed
with the traction to
ensure that there would be no displacement, also that there would be no skin
changes. However, there was
evidence of leg-length inequality. One was limited on the amount of weight one
could place with skin
traction. Because of this the patient was then taken to surgery after the leg-
length films showed a definite
shortening of the left lower extremity, and under general anesthesia a Steinmann
pin was inserted into the
distal left femoral fragment. The fracture was then manipulated, and he was placed
in balanced skeletal
traction. During that period of time, multiple x-rays including leg-length films
were obtained, and weights
were then adjusted in order to achieve a leg-length equality, and a fracture brace
was then applied with
heel cup and ankle hinge and polycentric knee hinges. The cast became loose, and
he was having
problems with further resolution of the swelling about the fracture site. The cast
was changed and
reapplied and placed in a fracture brace, long leg type. This time there was no
ankle hinge, only a
polycentric knee hinge. The patient was able to be discharged. He was to be seen
in 1 week as an
outpatient.
DISCHARGE DIAGNOSIS
Closed comminuted fracture of left femur.
1843 characters
Alternative: Russell traction. The use of the possessive form of eponyms is

acceptable when it is dictated or when
it is preferred by the employer or client.
PEDIATRICS DICTATION #1
OFFICE NOTE (2:00)
SUBJECTIVE
Patient is an 18-month-old Caucasian male here for followup of short stature. I
had spoken to Dr. (Blank)
earlier this week regarding his short stature; felt like this was consistent with
constitutional growth delay.
Suggested that likely his father was short and then had a sudden growth spurt.
This was confirmed by the
mother today. As long as the child is following the same curve in 6 months, we can
just follow;
otherwise, he would need to be seen for pediatric endocrinology evaluation. Has
been eating well now;
however, continues to pull at his ears.
OBJECTIVE
General: Alert, awake, very active, well-developed, well-nourished Caucasian
child. No apparent distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Red
reflex is positive.
Nares patent. Mouth: No lesions. Throat clear. Tympanic membranes are bilaterally
erythematous and
slightly dull. Neck is supple without adenopathy. Heart is regular rate and rhythm
without murmur. Lungs
are clear to auscultation. Abdomen is soft. There is no tenderness or
hepatosplenomegaly. Extremities:
There is good range of motion. Genitalia:1 Normal male child. Bilaterally
descended testicles. Anus is
patent. There are2 no rashes.
IMPRESSION
1. Short stature, likely constitutional.

2. Bilateral otitis media, improved; however, not completely resolved after a 10-
day course of
Augmentin.
PLAN
Will give a 14-day course of Augmentin and recheck ears in 2 weeks. We are also
checking a urinalysis
today and will check the patient�s height, weight, and head circumference at age 2
years. If at that time he
continues to follow the same growth curve, we will follow at 6-month intervals. If
he has fallen off the
curve, we will refer for pediatric endocrinology evaluation.
1779 characters
1 Expand abbreviations used in headings. Use genitalia rather than genitourinary

is the physical examination.
2 Edit is to are for subject-verb agreement (�rashes . . . �).

ADMITTING DIAGNOSIS
Possible foreign body in airway.
FINAL DIAGNOSISi
1. Spasmodic croup
2. Pharyngitis.
3. Mild bronchitis.
Treatment consisted of croup tent, antibiotic. Hospital course was uneventful.
Once he was in the croup
tent, his problems resolved. He was treated with Ceclor 125 mg 3 times a day, and
his chest
x-ray was clear. He was released, doing well, to be followed as an outpatient.
415 characters
i Alternative: Type diagnoses as dictated in narrative form.

ADMISSION DIAGNOSIS
Head injuries, skull fracture, concussion.
DISCHARGE DIAGNOSIS
Head injuries, skull fracture, concussion.
HISTORY
This 3-year-old child was brought to the emergency room after he was involved in a
car accident with an
injury to the head. Was seen in the emergency room. Was found to have a skull
fracture. A CAT scan was
done which was negative. The child was admitted for observation. During the
hospital stay, he was seen
to be very lethargic, vomiting. His neurological examination was essentially
negative. He is discharged
home on no antibiotic, for followup in the office.
COMPLICATIONS
None.
SURGERIES
None.
649 characters

HISTORY1
This 11-year-old presented with diabetes ketoacidosis (DKA)2 after an
approximately 2-week history of
not feeling well and lethargy. There was also a history of polyuria. He was
evaluated and found to have
an elevated glucose by a Glucometer reading and urine containing a large amount of
acetone. There was
no evidence of a precipitating cause for the diabetic ketoacidosis.
HOSPITAL COURSE
Laboratory on admission included a venous pH of 7.2, a CO23 content of 10, glucose
445, normal CBC.
The patient was treated with intravenous fluids and IV insulin, which brought
about resolution of the
diabetic ketoacidosis by 18 hours after admission. The process of teaching the
mother about insulin
administration, glucose monitoring, and diet was initiated in the hospital.
DIAGNOSIS
Diabetic ketoacidosis.
DISCHARGE INFORMATION
Condition: Recovered. Medication: Novolin NPH insulin 23 units one-half hour
before breakfast and 23
units one-half hour before supper. A 2200-calorie ADA diet. The mother was to
monitor glucose a.c. and
at bedtime.4 Followup arrangements with the diabetes educator were made for the
day after discharge and
followup 1 week after discharge.
1194 characters

2 Expand abbreviations on first use and place the abbreviation within parentheses.
3 Alternative: CO2.
4 The dictated abbreviation �q.h.s.� is on the list of dangerous abbreviations and
should be replaced with at bedtime.

INITIAL OFFICE EVALUATION (1:30)
HISTORY1
Patient is a 12-year-old with a history of asthma, hospitalized 3 times in the
past for asthma, and patient
has never been intubated. Patient is currently on no medications. Patient states
she has approximately 3
episodes of asthma per year, last episode January of this year necessitating an ER
visit with treatment
with Augmentin, Theo-Dur, Proventil, and Cardec DM.
Patient currently doing fine. No complaints. No shortness of breath, wheezing,

chest pain. Patient
currently without menarche.
GENERAL: Patient alert, active, no distress.
HEENT: Right canal with some impacted, hard cerumen. Nose is patent. No discharge,
no erythema.
NECK: Neck is supple with some shotty anterior cervical adenopathy bilaterally.
Nontender.
LUNGS: Lungs are clear bilaterally to auscultation. No rales or wheezing heard. No
retractions seen.
HEART: Heart is regular rate and rhythm.
ABDOMEN: Abdomen is soft. No masses, no organomegaly. No costovertebral angle
(CVA)3 or
suprapubic tenderness. Positive bowel sounds.
EXTREMITIES: Extremities without edema. Full range of motion.
SKIN: Skin without lesions.
NEUROLOGIC:4 Strength 5/5 in all extremities. Sensation grossly intact. Cranial
nerves 2-12 grossly
intact.
ASSESSMENT
1. Healthy 12-year-old.
2. History of asthma, currently asymptomatic.
PLAN
Patient given prescription for Proventil inhaler to use on a p.r.n. basis 2 puffs
q.6 hours5 as needed.
Patient also told to use Ocean nasal spray p.r.n. for tickle in her throat.
Patient to follow up in 1 year or
sooner if she develops any problems.
1595 characters
5 Alternative: q.6 h. or
every 6 hours.

ADMISSION DIAGNOSIS
Newborn infant.

The patient was a newborn baby girl following a full-term pregnancy. Complication
in the pregnancy was
gestational diabetes which was well controlled on a diabetic diet. Baby was born
by primary C-section
following a prolonged 2nd stage of labor with failure to progress and
cephalopelvic disproportion. The
time of birth was 7:05 a.m. The Apgar scores were 8 at one minute and 9 at five
minutes. Birth weight
was 8 pounds 7 ounces. Baby�s length was 21 inches and head circumference 35.5
inches.
Examination soon after birth was normal except for a moderate caput.
HOSPITAL COURSE
The patient�s only complication postpartum was a low-running glucose. For the
first 24-36 hours, blood
sugars were running in the 30s to 60 range. Breast-feeding was only being
accomplished with marginal
success due to some lack of eating enthusiasm by the baby. Therefore, gavage
feedings with formula were
initiated, and these resulted in elevations of the blood sugar to normal levels,
and then soon the baby
began to take standard oral feedings and breast-feeding very well. There was some
slight jaundice noted
on days2 2 and 3 of life, but this resolved spontaneously. On3 the baby girl�s 4th
day of life, the glucose
returned to the 90-120 range. The physical exam was unremarkable. The baby was
feeding well and was
discharged home with the mother that day.
DISCHARGE DIAGNOSIS
Full-term infant girl born by primary cesarean section.4
ADDITIONAL DIAGNOSIS
Transient hypoglycemia secondary to mother�s gestational diabetes.
DISCHARGE INSTRUCTIONS
The mother will be breast-feeding the child, and no medications will be needed.
The
child is to follow up in 2 weeks at the family practice center with the mother.
1795 characters

2 Edit day to days for accuracy.
3 Insert On to complete the sentence.

CHIEF COMPLAINT
Left-sided neck swelling, increasing secretions, breathing problems.

The patient is an 11-month-old white male with a 1-day history of cough and
congestion increasing over
the last day. He was seen in the office this morning with some shortness of
breath, congestion, with
diagnosis of pharyngitis, early bronchitis. He did have some small reactive lymph
nodes bilaterally in the
cervical region. Patient�s parents noted increasing size of the lymph node on the
left side over the
subsequent 6-8 hours. He was seen and evaluated in the emergency room, found to
have marked
enlargement of the left cervical lymph nodes with some pharyngeal soft tissue
swelling. He is now
admitted for inpatient treatment.

Prior hospitalizations: None. Patient has a history of several episodes of otitis
and bronchitis; has been
treated with several antibiotics for this. Grandparents with history of
hypertension. No other illness in the
family including tuberculosis (TB),1 carcinoma, heart disease, pulmonary disease,
seizure disorders.
SOCIAL HISTORY
Patient lives with parents and 4-year-old male sibling. Parents both smoke.
VITAL SIGNS:3 Temperature 103.9, pulse 160, respirations 44.
GENERAL: Patient is seen as a slightly lethargic 1-year-old with mild to moderate
secondary to secretions and upper respiratory airway narrowing.
HEENT: Eyes unremarkable. Tympanic membranes (TMs): Faint erythema bilaterally.
Throat reveals
mild erythema; no exudate is noted. There is soft tissue swelling on the left side
approaching the uvula.
No other oral lesions are noted.
NECK: The neck reveals marked swelling of the left neck with a firm, tender,
approximately 5- to 6-cm
mass on the left side and a smaller lymph node present on the right approximately
2 cm in diameter. No
other lymphadenopathy is noted in the supraclavicular region or inguinal area.
CHEST: The chest reveals increased upper respiratory sounds.
HEART: The heart reveals a regular rate and rhythm without murmur.
ABDOMEN: The abdomen is soft.
GENITALIA:4 Normal male. A wee bag5 is present.
EXTREMITIES: Unremarkable.
NEUROLOGIC: Slightly lethargic but otherwise acts appropriately.
LABORATORY
CBC, blood culture, electrolytes are pending. Also an x-ray of the chest6 and soft
tissue of the neck is
pending.

IMPRESSION
1. Primary left lymphadenitis, left cervical area.

2. Early otitis media.
3. Pharyngitis.
PLAN
The patient will be admitted for antibiotic coverage, mist tent, handling of
secretions, and monitoring.
2580 characters

4 Expand abbreviations used in headings. Use genitalia rather than genitourinary
in the physical examination.
5 The dictated wee bag could be edited to urine collection bag.
6 Edit chest x-ray to x-ray of the chest for accuracy. One x-ray of a small child
takes in both the chest and neck at
one time.

OFFICE NOTE (1:00)
A1 10-month-old white female child here for recheck today of ears. She has had no
fever at home. The
mother states that she and her daughter are flying in 3 days.
OBJECTIVE
Alert, oriented white female child crying during exam. Temperature 99.7 rectally.
Weight 21 pounds 9
ounces. Ears: Tympanic membranes, left, slight erythema noted. Decrease in light
reflex, right, without
obvious erythema. Neck supple. Chest clear to auscultation bilaterally. No wheeze
or rhonchi.
Cardiovascular (CV):2 Regular rate without murmur. Abdomen soft, nontender.
Negative
hepatosplenomegaly. Perineum: Normal female; however, ruptured vesicles noted
around perianal area.
Extremities: Without lesion.
ASSESSMENT
A 10-month-old white female child with early left otitis media and probable
candidal diaper dermatitis.
PLAN
1. Septra suspension 1 teaspoon p.o. b.i.d. for3 10 days.

2. To administer Lotrimin cream and hydrocortisone cream 0.5% separately to diaper
area in an attempt
to improve rash.
3. Recheck in 10 days.
4. Caution given to mother to begin feeding child upon takeoff of aircraft in
order to reduce possibility of
increased inner ear pressure. Mother cautioned against possible difficulties of
aircraft flight with early
infection; however, no fluid behind drum is noted.
1280 characters
1 Insert an article to avoid beginning the sentence with a number.

as for rather than using times or x.

A 3-month-old who developed a fever. She had few symptoms other than a fever of
100.4 on presentation
to the office. She had a little bit of poor feeding pattern according to the
mother, otherwise was doing
fine. On that day her rapid strep was negative and her urinalysis showed small1
leukocytes. The mother
had noted that she had had a sore throat and congestion. The child was evaluated
and felt to possibly just
have a virus, and it was elected to follow her clinically at that time.
She presented to the office with a history of a temperature maximum2 of 101.6 the
evening prior. She had
been sleeping most of the day and had poor p.o. intake according to the mother.
On physical examination, the infant was3 alert, nontoxic-appearing. Her head was
normocephalic,
atraumatic. Fontanel was open and soft. Conjunctivae were clear. Red reflex was
present bilaterally.
Tympanic membranes (TMs)4 were clear. Nose was clear. Pharynx was clear. Neck was
supple without
adenopathy. Lungs were clear. Heart was regular in rate and rhythm without murmur.
Abdomen was soft
and nontender without masses or palpable hepatosplenomegaly. Extremities were
without swelling or
tenderness.
The impression at that time was history of fever, irritability, and decreased p.o.
intake in a 3-month-old
with no focus of infection.
HOSPITAL COURSE
The infant was admitted and placed on Rocephin IV following blood, urine, and
spinal fluid cultures
being obtained. Her initial white count was 3700 with 29 polys, 13 bands, and 56
lymphocytes. Her
followup white count the following day was 5900 with 4 polys, 1 band, 84 lymphs,
and 10 monos. Her
blood, urine, and spinal fluid cultures were all negative at 48 hours. The child
was afebrile and doing
quite well, and it was decided to go ahead and discharge her home at that time. Of
note is the fact that the
maternal grandmother has had problems with chronic Epstein-Barr virus (EBV) and
cytomegalovirus
(CMV)5 infections. Titers to these two viruses were sent, and the results of these
are pending at the time
of discharge.
DISCHARGE DIAGNOSIS
1. Rule out sepsis. This was done.

2. Probable viral infection.
PLAN
1. The plan is to follow up on the EBV and CMV titers.

2. To have her follow up in our office in 1 week�s period of time so that she can
have her 2-month
immunizations which have been delayed due to illness.
2367 characters

1 Edit small leukocytes to a small number of leukocytes for accuracy.
3 The dictator changes from past to present to past tense; edit for consistency.
Since this is a discharge summary,
past tense is more appropriate.
parentheses.
parentheses.

PROGRESS NOTE (1:00)
This is about a 24-hour-old baby, septic. Has been having tachypnea, probably
pneumonia. Has done
fairly well through the night, the heart rate ranging 110-120 with periods of
bradycardia going down to
about 90, respirations1 of 110-120. The baby was on FIO22 about 25% during the
night, CO23 of about 30,
O24 of about 70-90.
The baby seems a little bit better. I did a spinal tap last night. The results of
that showed red count of 107,
white count of 4, CSF protein of 60, CSF glucose of 55. Continue to keep the baby
on the same treatment,
IV fluids. Change the IV to D10 in 0.20 normal saline5 with potassium and calcium
at 10 mL/hr.6 IV
ampicillin, IV Claforan, and we plan to do the electrolytes and calcium today.
740 characters
1 This passage should be flagged for verification by the dictator. In this

febrile, septic child the pulse of 90 is much
slower than the basal rate of 110-120. A respiratory rate of 110-120 (2 pants a
second) is an extreme tachypnea, if
not actually unbelievable. Since the same numbers occur for pulse and respiratory
rate, there are grounds for grave
doubt here that the respiratory rate is correct.
2 Alternative: FIO2 or FIO2.
3 Alternative: CO2 or CO2.
4 Alternative: O2.
5 The dictator says �point 2 normal saline.� Add a zero before the decimal for
values under 1. The safest way to
transcribe solutions of dextrose and normal saline is as shown.
replaced with the SI unit mL.

PROGRESS NOTE (1:00)
This newborn baby was born to a gravida 3, para 1, O positive mother, expected
date of confinement
(EDC)1 April 11,2 26-year-old mother, antibody screen negative, serology
nonreactive. Rupture of
membranes about 10 hours before delivery. A cesarean section was done because of
prolonged labor,
nonprogression. No evidence of any fetal distress. A female infant delivered,
spontaneous cry, was
suctioned. Good heart rate. Apgars of 7 and 9. Was given some oxygen, suction
done, and the baby
seemed to be doing fairly well. Gross physical examination was essentially normal.
Cord pH was done
which was 7.23.
IMPRESSION
A term female infant born through a cesarean section because of prolonged labor.
717 characters
Expand abbreviation on first use and place abbreviation in parentheses.
Transcribe a full date, if known.

HISTORY1
This is a term female born to a 22-year-old P 1-0-0-1, A positive Caucasian female
who had an
uneventful prenatal course. Previous pregnancy had pregnancy-induced hypertension.
The mother2 denies
taking drugs, medication, alcohol, tobacco, or other substances. The baby was born
spontaneous, vaginal,
vertex, Apgars 8 and 9. Was stabilized and transferred to the nursery.
VITAL SIGNS: Birth weight 4010 g, length 53 cm.
HEENT: Normocephalic. Anterior fontanel open. There is a bruise over the occiput,
a nevus flammeus on
the forehead. Eyes normal, ears normal, nose normal. Throat clear. Palate intact.
NECK: Supple. Clavicles intact.
CHEST: Chest expanded. Air entry equal bilaterally. No adventitious sounds.
HEART: Both sounds heard. No murmur.
ABDOMEN: Soft, no organomegaly. Bowel sounds present. Umbilicus: Two arteries, one
vein.
GENITALIA: Female.
ANUS: Patent.
EXTREMITIES: No abnormalities. Hips normal. Femoral pulses felt bilaterally.
NEUROLOGIC: Spine straight. Central nervous system grossly normal. Appropriate for
gestational age.
IMPRESSION
A term female.
PLAN
As per order sheet.
1163 characters

2 Edit for clarity; the dictator is talking about the mother, not the baby.

CHIEF COMPLAINT
This 1-month-old baby is being admitted for possible sepsis.

He was well until 1 week ago when fever and coryza began. Temperatures were noted
up to 102 rectally,
and he was treated only with Tylenol. Developed some eye discharge on the right
side 4 or 5 days ago but
no cough or vomiting or diarrhea. Was seen in the clinic this morning and noted to
be afebrile, but
Tylenol had been given just 2 hours earlier. Chest x-ray at that time was clear
though he did have nasal
congestion and purulent right eye discharge. A conjunctival scraping was sent for
chlamydia by direct
FA, and the baby was admitted for further workup and IV antibiotics.

Was born at term weighing 3230 g. Apgars were 8 and 9. Mom had a history of IV
drug use during
pregnancy but turned out to be negative for hepatitis B core antibody. Course was
remarkable only for
mild jaundice which did not require any treatment. Has been breast-feeding well
since then and gaining
weight. A couple of lesions on his foreskin were scraped for bacterial and herpes
culture and turned out to
be probably colonized with enterococci but responded well to topical Polysporin
ointment.
FAMILY AND SOCIAL HISTORY

Remarkable for an older sister who has epilepsy and an older brother who has a
nasal discharge at this
time, but this is not unusual for him. No one else in the home is ill.
REVIEW OF SYSTEMS
Unremarkable.
VITAL SIGNS: Weight is 3.9 kg,3 temperature 4 is 99.6 rectal, pulse 180,
respirations 50.
SKIN: Skin shows some papular lesions on the face only. No jaundice or vesicles.
HEENT: Fontanel is soft. Both tympanic membranes (TMs)5 normal and mobile. Right
palpebral fissure
appears slightly smaller than the left, probably due to swelling of the eyelids.
There is a purulent
discharge, greater on the right than the left, with minimal conjunctival
injection. Nares are congested with
whitish mucus. Pharynx is benign.
NECK: Neck is supple.
CHEST: Without retractions.
LUNGS: Clear.
HEART: Without murmur.
ABDOMEN: Soft without distention or organomegaly or obvious tenderness.
NEUROLOGIC: Appropriate-for-age baby who is alert and not very fussy.

LABORATORY6 RESULTS
Bag UA shows only 10-20 epithelial cells without any WBCs or RBCs or abnormalities
on dipstick. CBC
shows a white count of 10,0007 (18 polys, 72 lymphs, 7 monos, 3 eos). Hemoglobin
13.5, hematocrit
44.8. Platelets normal on smear.

PROBLEMS
1. History of fever�rule out sepsis.

2. History of vomiting�rule out meningitis.
3. Upper respiratory infection (URI)8 with conjunctivitis�rule out chlamydia.
ASSESSMENT
This baby does not9 look very �toxic,� but the mom says the rectal temperatures10
at home were up to 102
for the past week. Spitting up after breast feedings just began since admission
but should be watched
carefully since I was unable to obtain any spinal fluid after 3 attempts.
PLAN
Blood cultures and urine culture are pending. Will repeat lumbar puncture (LP)11
if he does not improve
clinically. IV hydration. Ampicillin 200 mg/kg/day12 and cefotaxime 100 mg/kg,13
both divided q.6
hours14 IV. Mist tent with bulb suction of the nares p.r.n. Will watch fever curve
carefully without any
antipyretics.
3253 characters
1 The dictator says �HPI,� which should be expanded in a heading.

3 Edit slang kilo to appropriate abbreviation for kilogram (kg).
7 Express full numeric value. Alternative: 10 thousand.
12 Pediatric dosages of medication are based on weight of the patient; it is
appropriate to use two virgules (slashes)
in expression of a dosage.
13 Edit slang kilo to appropriate abbreviation for kilogram (kg).
14 Alternatives: q.6 h. or every 6 hours.


This is a 16-month-old white female air-lifted for hyperbaric treatment for carbon
monoxide poisoning.
Evidently the source of carbon monoxide was the household furnace. There was no
fire or smoke
involved. Patient lost consciousness and was apneic for an undetermined amount of
time per her parents.
She was also vomiting, and there is a question of aspiration. The parents state
that she now appears okay
and is somewhat irritable. She tolerated the hyperbaric treatment well.
ALLERGIES
No known allergies.
MEDICATIONS
None.
IMMUNIZATIONS
Up-to-date.

Has been healthy since birth. Has not been hospitalized. Had 1 episode of otitis
media requiring a short
course of amoxicillin.
SOCIAL HISTORY
Lives with mother and father. No brothers or sisters.
FAMILY HISTORY
Unremarkable.
REVIEW OF SYSTEMS
Unremarkable.
GENERAL:3 Somewhat irritable. Temperature 98�.
HEENT: Tympanic membranes are reddened bilaterally. Good light reflex, no fluid.
Patient crying at the
time of the exam.
NECK: Supple without thyromegaly.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmur, S3, or S4.4 No thrills or heaves.
ABDOMEN: Benign. Bowel sounds are present.
EXTREMITIES: Without clubbing, cyanosis, or edema. Pulses +4/4 and symmetrical.
NEUROLOGIC:5 Deep tendon reflexes +2/4. Cranial nerves 2-12 appear intact. Moving
all 4 extremities
well.

LABORATORY DATA
Arterial blood gases: pH 7.20, pCO2 of 36, pO2 of 331,6 bicarbonate7 14 on 100%
O2.
Carboxyhemoglobin 9.0. EKG: Normal sinus rhythm without acute ST or T-wave
changes. Chest
x-ray was within normal limits.
ASSESSMENT
Significant carbon monoxide poisoning.
PLAN
There is some question as to whether the carboxyhemoglobin reflected the extent of
the carbon monoxide
exposure. She is status post hyperbaric treatment and doing well at this time.
Being admitted for
observation overnight. Will monitor vital signs q.4 hours8 with neuro checks. Will
also monitor
temperature closely since there is some question as to whether or not she
aspirated stomach contents. We
have contacted Speech Pathology9 to perform a Denver Developmental Screening Test
(DDST)10 to
assess for possible anoxic brain damage. If the DDST is normal and there are no
acute changes, will
discharge11 in the morning.
2333 characters
1 Expand abbreviations in headings.

4 Alternative: S3, or S4.
6 Alternatives: PCO2 and PO2 or PCO2 and PO2.
8 Alternatives: q.4 h. or every 4 hours.
11 The dictated �D/C� is on the list of dangerous abbreviations and should be
edited to discharge or discontinue,
depending on context.

APPENDIX
Quick-Reference List of Medical Words and Phrases

Index to Medical Reports

Quick-Reference List of Medical Words and Phrases
A, a
AB or ab (abortion)
abate
abdominal cramps
abdominal flat plate
abdominal girth
abdominal hysterectomy
abdominal ileus
abdominal mass
abdominal pedicled graft
ABG , ABGs (arterial blood gas [gases])
abrasion
abscess cavity
abscess of nose
AC (acromioclavicular) joint
accelerated idioventricular rhythm (AIVR)
accelerations
accentuation
accidentally
accommodation
Accu-Chek meter
acetaminophen
acetone
Achilles tendon bursitis
acid-base status
acid-fast bacilli
ACL (anterior cruciate ligament) reconstruction
ACLS (advanced cardiac life support)
acne
acne vulgaris
acute bronchitis
acute surgical abdomen
ADA diet
adenocarcinoma
adenoidal hypertrophy
adenopathy
adenotonsillectomy
adenotonsillitis
adipose
adjustment disorder
adnexa
adnexa nontender
adnexal area
adnexal mass
Adriamycin
adventitious sounds
Advil
aerobic gram-negative rods
aerosolized pentamidine prophylaxis
afebrile
against medical advice
aggressive behavior
aggressive chemotherapy
agitated
agonal
agoraphobic
AIDS (acquired immunodeficiency syndrome)
air entry
air entry equal
air interface
air in the biliary tree
air-lifted
airway narrowing
AIVR (accelerated idioventricular rhythm)
albumin
albuterol inhaler
alcohol addiction
alcohol-induced pancreatitis
alcohol-related pancreatitis
alcohol neurological syndrome
alert and oriented
alimentation
�alk phos� (slang for alkaline phosphatase)
alkaline phosphatase
Alka-Seltzer Plus
ALL (acute lymphoblastic lymphoma)

allergic rhinitis symptoms anoxic brain damage
allergy to insect bites antacids
allopurinol antecedent
alpha blockers antecubital fossa
Alupent antecubital space
Alzheimer disease anterior and posterior vaginal repair (A&P
amaurosis fugax repair)
AMBI hip screw anterior chamber of eye
ambulatory with effort anterior cubital fossa
amiodarone anterior fontanel, fontanelle
ammonia anterior-inferior capsular shift
amnioinfusion anterior septal
amniotic fluid anterior wall
amoxicillin anteromedial joint line
Amoxil anteroseptal myocardial infarction
�amp� (slang for ampule) antibiotics
amphotericin B antibody negative
ampicillin antibody screen
ampule (slang �amp�) antibody screen negative
amputee antidepressant
amylase antiemetics
anal canal antipyretics
analgesia antisteroidals
analgesic Antivert
anal prolapse anulus (not annulus)
anal sphincter anus patent
anal tone anxiolytic agent
anal verge anxiolytics
Anaprox DS aortic leaflets
anastomotic aortic stenosis
Ancef aortofemoral bypass graft surgery
androgen ablation AP (anteroposterior)
anemia apex
anemic Apgar score (Apgars)
anesthetized apical impulse
aneurysmal dilatation apical rate
aneurysmal formation of aorta apneic
angina pectoris A positive
angina with effort A positive Caucasian female
ankle edema appendectomy
ankle jerk appendicitis
ankle mortise appendix
anoplasty applanation
anorectic appropriate for gestational age
anorexia appropriate-for-age baby
anorexic ARDS (adult respiratory distress syndrome)

areola
arrhythmia
arterial blood gases
arterial insufficiency of lower extremities
arteriosclerotic heart disease
arthralgias
arthritis
Arthrotec
artifact
artificial rupture of membranes
as per order sheet
ASA (acetylsalicylic acid) (aspirin)
ASCVD (arteriosclerotic cardiovascular disease)
aseptic meningitis
ASO titer
aspirated
aspirin
ASPVD (arteriosclerotic peripheral vascular
disease)
assess
AST (aspartate aminotransferase) (formerly
SGOT)
asterixis
asthma
ASTRA or Astra analyzer
asymmetry
asymptomatic
asystole
at bed
at bed rest
atelectatic infiltrate
atherosclerosis
athletic supporter
atopic dermatitis
atraumatic
atrial complex
atrial enlargement
atrial fibrillation
atrial flutter
atrial pacemaker
atrophic endometrium
atrophic vaginal introitus
atrophy of testicle
Atrovent inhaler
atypia
atypical-appearing lymphocytes
Augmentin
auscultatable
auscultation
Austin Moore prosthesis
AV (atrioventricular)
AV block
AVF
a while (two words)
axilla
axillary lymphadenopathy
axillary nerve distribution
axillary tumor removal
axis deviation
azotemia
AZT (former name of zidovudine)
B, b
Babinski sign
bacillus
backup method
bacteremia
bacterial culture
bacteriuria
Bactrim
bag UA (urinalysis)
balanced skeletal traction
barium enema
barium esophagram
barium swallow
Bartholin gland
Bartholin�s, urethral, and Skene�s glands
basilar infiltrates
basophilic stippling
bathroom privileges
BCC (basal cell carcinoma)
Beconase inhaler
bed mobility
beefy red pharynx
belligerent behavior
Benadryl
benign nodular hyperplasia
beta strep culture

Betadine prep
bibasilar infiltrates
�bicarb� (slang for bicarbonate)
bicarbonate (slang �bicarb�)

biceps tendinitis
b.i.d. (twice daily; twice a day)

bilateral tubal ligation
bilaterally
bile duct anastomoses
bile leak
�bili� (slang for bilirubin)
biliary drainage
biliary ductal dilatation
biliary sludge
bimanual examination
birth control pills
bitemporal headache
BK (below-the-knee) amputee
black stool
bladder dysfunction
bladder outlet obstructive symptoms
bland diet
blast cells
blasts
bleeding esophageal varices
blepharitis
blind pouch
bloating
blockage
blood chemistries
blood clot
blood culture
blood cultures x2 (times 2)
blood gases
blood gases on room air
blood sugar
blood, urine, and spinal fluid cultures
bloody urethral drainage
blurred vision
boggy mucous membranes
bone marrow aspiration
bone marrow biopsy
bone scan
bone spur
bony involvement
borderline sepsis
bowel habits
bowel movement
BP (blood pressure)
BPH (benign prostatic hyperplasia)
B positive
bra straps
bradycardia
bradycardic
bradyrhythmia
brain damage
brain stem
bran therapy
breast biopsy
breast feeding
breast lump
breathlessness on exertion
breech delivery
breech presentation
Brethine
bretylium
brisk and equal
broad spectrum antibiotics
bronchial breath sounds
bronchial washings
bronchial-type of cough
bronchitis
bronchodilator
bronchogenic carcinoma with bilateral
dissemination.
bronchoscopy
brown stool
Brudzinksi�s sign
bruit (pl. bruits)
B strep (beta streptococcus; group B
streptococcus)
B12, B12 level
bulb suction of nares
bulb syringe
bulbar ulcer
bulbar urethral stricture
bulging bag of water
bulging of disk
bulk of stool
bulky metastatic melanoma of axilla
bullous pemphigoid
BUN (blood urea nitrogen)
bundle branch block
Burow soaks
bursitis
BUS (Bartholin�s, urethral, and Skene�s glands)

butterfly fragment of femur
by (x as in 2 x 3 x 5 cm)
bypassing
C, c
cachectic
cachexia
caffeine abuse
calcaneus
calcification of the mitral anulus
calcium
calcium phosphate crystals
calf tenderness
candida organism
Candida albicans
candidal diaper dermatitis

cannulated hip pinning
CA-125 level
captopril
caput
Carafate
carbon monoxide poisoning
carboxyhemoglobin
carcinoma of prostate
Cardec DM
cardiac asystole
cardiac enzymes
cardiac index
cardiac margin
cardiac monitor
cardiac output
cardiomyopathy
cardiorespiratory arrest
cardioversion
cardioverted
Cardizem
Cardura
�cath�d� (slang for catheterized)
carina
carotid artery atherosclerosis
carotid endarterectomy
carotids
carotid surgery
carpal tunnel release
casts
CAT (computerized axial tomography)
CAT scan
cataract extraction
cath�d� (slang for catheterized)
catheter drainage
catheterized urinalysis
Caucasian
caudal portion of the septum
cauterized
cautery
CBC (complete blood count)
CBC with differential
cc (cubic centimeter)
Cefazolin
Cefobid
cefotaxime
cefuroxime
cellulitis
cellulitis of nose
central canal stenosis
central retinal artery occlusion
central venous catheter placement
Cepacol mouthwash
cerebellar
cerebral aneurysm
cerebral arteriosclerosis
cerebral atrophy
cerebral hemorrhage
cerebral palsy
cerebrovascular arteriosclerosis
cerumen occlusion in ear
cervical adenopathy
cervical laminectomy
cervical motion tenderness
cervical region
cervical traction
cervicitis
cervix
cervix intact
cesarean delivery
cesarean section
chandelier sign
cheiloplasty
chemistry profile
chest wall abscess
chest x-ray
CHF (congestive heart failure)

chipper codeine
chlamydia organism coffee-grounds emesis
cholangitis coffee-grounds material
cholecystectomy coffee-grounds vomitus
cholecystitis coffee-grounds-type substance
cholelithiasis colitis
cholesterol collateral circulation
chondral collateral laxity
CHOP (cyclophosphamide, colonic evaluation
hydroxydaunomycin, Oncovin, prednisone) colonic workup
chromic suture colonized
chronic fatigue syndrome colonoscopy
chronicity colostomy
CIE (counterimmunoelectrophoresis) comatose
ciprofloxacin combative
circumcised penis comminuted fracture
circumference of leg comminuted ulnar shaft fracture
circumflex coronary artery compartment syndrome
Claforan Compazine
clavicle fracture compensated hyperventilation pattern
clavicles Compleat
cleft lip-palate deformity complications
clicks at the apex compromise
clinical evidence condom
Clinoril confluent
clofibrate congested testicle
clonus congestion
closed fracture-dislocation of elbow congestive heart failure
closed head injury conjugate
clots in bladder conjunctiva (pl. conjunctivae)
clubbing conjunctiva injected
cm (centimeter) conjunctival erythema
CMV (cytomegalovirus) conjunctival injection
CMV infection conjunctival scraping
CMV panel consensually
CMV titers conservative treatment
CNS (central nervous system) constipated
CO2, CO2 (carbon dioxide) constitutional growth delay
coagulase-positive Contac
coagulation contiguous
coarse expiratory wheezes contracted
coarse ventricular fibrillation contracture deformity
cocaine contraindicated
coccidioidomycosis of lung contusion
Code Blue convalescence
coded convulsion

COPD (chronic obstructive pulmonary disease)
cord pH
cord structures palpable
coronary angiogram suite
coronary arteriography
coronary artery bypass graft
coronary artery disease
coronary disease
coronary insufficiency
cortisol
cortisone shot
coryza
costal margin
costochondral junction
costochondritis
Coumadin anticoagulation
countershocked
Covera
CPD (cephalopelvic disproportion)
CPK (creatine phosphokinase) isoenzyme
CPR (cardiopulmonary resuscitation)
crackling cough
crampy
crampy abdominal pain
cranial nerves 2-12
craniofacial surgery
creamy sputum
creatinine
crepitation
crepitus
crescendo-decrescendo systolic murmur
Crohn disease
cross-body blocked
cross-legged
croup tent
crusted lesion
crusted nasal discharge
crusty rash
cryopexy of retinal tear
cryoprecipitate
cryosurgical ablation
cryptococcal infection
Cryptococcus
crystalloid
C-section (cesarean section)
CSF (cerebrospinal fluid)
CSF glucose
CSF protein
C6 radiculopathy
CT (computerized tomography)
CT scanner
cubic centimeters (used for volume of tissue or
other solid objects)
cuff rupture
cul-de-sac
culdoplasty
culture and sensitivity
curvature
curvature of nose
CVA (cerebrovascular accident)
CVA (costovertebral angle) tenderness
cyanosis, clubbing, or edema
cyanotic testicle
cycles per second
cystic-appearing lesion
cystic-like structure
cystic lump in breast
cyst in breast
cystoscopy
cytologic brushing
cytomegalovirus (CMV)
D, d
D&C (dilatation and curettage)

dark stools
Darvocet
Darvocet-N
dazed
D/C (discharge; discontinue)
DDST (Denver Developmental Screening Test)
debilitation
debridement
debridement of lateral meniscal tear
debulking of liposarcoma
deceleration
decompensation
decreased sensation to pinprick
decubitus
deep tendon reflexes
deep vein thrombosis in calf
deferred
defervesced

deficient differential
deficit differential profile
degenerated lumbar disk diffuse pattern
degenerative disease digital nerve block
degenerative joint disease digitalis level
degree (�) digitalized
dehydration hyponatremia digoxin
delayed emptying Dilantin level
delirium dilated small bowel
delirium tremens dilation
dementia dilation of urethra
Demerol Dilatrate
demineralization Dimetapp
dental caries diminished breath sounds
dentition diminished pain
dentures diminution
Denver Developmental Screening Test (DDST) diphtheria-tetanus injection
dependent edema diplopia
Depends dipstick
Depo-Lupron dipyramidole (Canadian)
Depo-Medrol dipyridamole (U.S.)
depression dire straits
dermatitis direct FA (fluorescent antibody) test
descended testes disabling
detorsion of testicle discoloration
detox facility disimpaction of rectum
detoxification disk herniation
developmental skeletal discrepancy disks
deviating the trachea disks sharp
D5 in half-normal saline distal bulbar stricture
D5 in Ringer�s lactate distal humerus oblique fracture
diabetes mellitus distal phalanx
diabetic diet distended
diabetic foot ulcer Ditropan
diabetic ketoacidosis diurese, diuresed
diabetic neuropathy diuresis
diabetic retinopathy diuretic
diagnostic arthroscopy diverticula
dialysis diverticular mass
diaper dermatitis diverticulosis
diaper rash diverting colostomy
diaphragmatic excursions dizziness
diarrhea DKA (diabetes ketoacidosis)
diastolic dL (deciliter)
diazepam dobutamine
�diff� (differential) dorsal spine

dorsalis pedis pulse
dorsum
dorsum of foot
double-bubble deformity
double vision
Dove soap
downgoing toes
downhill course
DPs (dorsalis pedis) pulses
drainage on perineum
draining sinus
drawer sign
D10 in 0.20 normal saline
DTRs (deep tendon reflexes)
Dyazide
Dynapen
dysfunction
dysmenorrhea
dyspepsia
dysphagia
dysplasia of cervix
dysplasia of endocervix
dyspnea
dyspnea on exertion
dyspneic
dysproteinemia
dysuria
E, e
ear tube placement

early labor, transitional stage
earwax
EB (Epstein-Barr) virus
EBV (Epstein-Barr virus)
EBV panel
ecchymosis (pl. ecchymoses)
ecchymotic
ECG, EKG (electrocardiogram, -graph)
echocardiogram
E coli (Escherichia coli)
Ecotrin
ECT (electroconvulsive therapy)
eczema
ED (emergency department)
EDC (expected or estimated date of
confinement)
edema
edentulous
EEG (electroencephalogram, -graph)
effaced
effusion
effusive knee
18-French catheter
ejection fraction
EKG, ECG (electrocardiogram, -graph)
elective procedure
electrolyte imbalance
electrolytes (slang �lytes�)
emergent operation
emesis
emphysema
emphysematous gallbladder
empiric
empirically
emptying of bladder
endarterectomy
endocervical curettage
endometriosis
endoscopy
enhanced CT scan
Ensure
Ensure Plus
enteral feeding tube
enteric pathogens
enterococcus (pl. enterococci)
enucleation of eye
EOM (extraocular movements)
EOMI (extraocular movements intact)
eos (eosinophils)
epidural anesthesia
epidural steroid injection
epigastric tenderness
epilepsy
epinephrine
episiotomy
epistaxis
epithelial cells
Epstein-Barr virus (EBV)
Epstein-Barr virus syndrome
equal expansion
ER (emergency room)

ERCP (endoscopic retrograde
cholangiopancreatography)
erection
ergocalciferol
eroded
erratically
erythema
erythematous rash
erythromycin
Escherichia coli (E coli)
Escherichia coli pyelonephritis
esophagitis
esophagogastroduodenoscopy
essential hypertension
estimated blood loss
estimated date of confinement (EDC)
estimated fetal weight
estrogen replacement therapy
ESWL (extracorporeal shock wave lithotripsy)
etiology
eupneic
exam (examination)
examining glove
excision of Peyronie�s plaque and graft to penis
excoriation of perineum
excursions
exercise restriction
exercise tolerance test
exertion
exertional chest discomfort
expected date of confinement (EDC)
expectorating
expiratory wheeze
exploratory laparotomy
exquisite point tenderness
extensive exercising
external ear canal
external fetal monitors
extraocular motility
extraocular movements intact
extrapyramidal motor symptoms
extubated
exudate
exudative pharyngitis
eyedrops
F, f
facet joint
facial cellulitis
failure to progress
fascicular block
fasciocutaneous flap
fasciotomy
fatal arrhythmia
fatigue
fatty foods
fatty metamorphosis of the liver
fecal impaction
feeding gastrostomy tube
femoral arteries
femoral bruit
femoral condyle
femoral fragment
femoral neck collapse
femoral neck fracture
femoral pulses
ferritin
ferrous sulfate
fetal distress
fetal growth
fetal heart tones
fetal movement
FEV (forced expiratory volume)
FEV-1, FEV1 (forced expiratory volume in 1
second)
fever curve
FFP (fresh frozen plasma)
fibrocystic breast
fibrous histiocytoma
fibula
fibular shaft fracture
fingerstick blood sugar
finger-to-nose test
FIO2 (fractional inspired oxygen concentration)
1st degree AV block
1st generation cephalosporins
fist palpation
fist percussion
fistula (pl. fistulae, fistulas)
5-FU and leucovorin chemotherapy
fixed and dilated pupils
Flagyl

flaking
flank pain
flat film of abdomen
flat neck veins
flatus
fleeting pain
Flexeril
flexion and extension movements
flexion contracture
floaters
Flomax
fluctuancy
fluid behind drum
fluid bolus
fluid overload
fluid retention
fluorescein angiography
focal disk herniation
focal infiltrates
focal neurologic deficits
focal squamous metaplasia
focus of infection
folate level
Foley catheter
folic acid level
followup
fontanel, fontanelle
food sticking in throat
foraminotomy
force and caliber of urinary stream
force fluids
foreign body in airway
foreskin
fossa (pl. fossae, fossas)
fracture brace
fracture-dislocation of elbow
fracture fragments
fracture of neck of femur
free air
free intraperitoneal air
free T4
frequency of stool
frequent urination
friable cervix
full-term pregnancy
fundus (pl. fundi)
funduscopic
funduscopy
fungal culture
furosemide
fussiness
G, g
g (gram)
G (gravida)
gagging
gait
gallbladder
gallbladder sonogram
gallium scan
gallop
gamma globulin therapy
Gammagard therapy
gangrenous cholecystitis
gardnerella organism
gardnerella vaginitis
gastrectomy
gastric irritants
gastric stimulants
gastritis
gastroenteritis
gastrointestinal bleed
gastrojejunostomy
gastrostomy tube drainage
Gatorade
gavage feeding with formula
GC (gonorrhea) culture
g/dL (grams per deciliter)
gemcitabine
general anesthesia
generalized osteoarthritis
genitalia
gentamicin
gestational diabetes
GGT (gamma-glutamyl transpeptidase)
GI (gastrointestinal)
girth
glaucoma
Gleason score 5, clinical stage T2b
glenohumeral instability
glomerulonephritis
Glucola liquid for glucose tolerance test

Glucometer
glucose
glucose tolerance testing
Glucotrol
gluteal area
golf ball-sized scrotal mass
gout
grafting
gram-negative
gram-positive cocci
Gram stain
Gram stain of sputum
granulation tissue
granulomatous colitis
gravida (G)
griseofulvin
groin flap
groin hernia
Groshong catheter
gross deficit
gross physical examination
group B strep (group B streptococcus)
group D enterococcus
group D strep
GU (genitourinary)
guaiac
guaiac-negative stool
guarded prognosis
guarding
gum line
gynecomastia
H, h
Haemophilus influenzae
Haldol
half-squat
H&H (hematocrit and hemoglobin)
H&P (history and physical)
Harrington rods
harsh cough
hay fever
HbsAg antigen
HCTZ (hydrochlorothiazide)
head circumference
headache
healing per primam
health screen
heaves
Heberden nodes
heel cup and ankle hinge
heel insertion area
HEENT (head, eyes, ears, nose, throat)
hematemesis
Hematest-negative
Hematest-positive
hematochezia
hematocrit
hematologic malignancy
hematopoietic
hematuria
heme-negative mucus and stool
heme-negative stool
heme-positive stool
hemiarthroplasty, bipolar type, to hip
hemiparalysis
hemiparesis
hemipelvis
hemispheric
Hemoccult
Hemoccult-negative
Hemoccult-positive
Hemoccult test
hemodynamically unstable
hemoglobin
hemoglobin A1c
hemogram
hemoptysis
hemorrhagic lesion
hemorrhoidectomy
hemorrhoids
heparin drip
hepatic encephalopathy
hepatitis
hepatitis antigens
hepatitis B core antibody
hepatojugular reflux
hepatosplenomegaly
herniated disk
herniated lumbar disk
herpes culture
herpes simplex
heterophile

hiatal hernia with esophageal reflux
Hibiclens soaks
hiccups
Hickman catheter
HIDA scan
high fiber or bran
Hispanic
histiocyte
HIV (human immunodeficiency virus)
HIV test
hoarseness
hollow viscus
Homans sign
home birthing room
Home Health Care
Home Health nursing visits
hormonal therapy
hostile
hot kidney
hourglass figure
house-confined amputee
hpf (high-power field)
HPI (history of present illness)
Hubbard tub
Hycomine
hydrated
hydration
hydrocele repair
hydrocortisone cream
hydroxyzine
hygienic
hyperalimentation
hyperbaric treatment
hypercholesterolemia
hyperemesis of pregnancy
hyperglycemia
hyperinflation of chest
hyperlipidemia
hyperpigmented area
hyperpigmented nevus
hyperpigmented spots
hyperreflexic
hypertension
hypertensive nephrosclerosis
hypertrophic changes
hypertrophic sigmoid diverticulosis
hypertrophied turbinates
hyperuricemia
hypoactive bowel sounds
hypocalcemia
hypoglycemia
hypokalemia
hypomagnesemia
hypoplasia
hypostatic changes
hypotension
hypotensive
hypothyroidism
hypovolemia
hysterectomy
hysterical
I, i
icterus
idiopathic edema
IgG level
IgG subclass deficiency
IgG subclass immunodeficiency
ileus
IM (intramuscular)
immature forms
immobile
immobility
immunizations
immunodeficiency
immunoelectrophoresis
Imodium
impetigo
implant of hydroxyapatite sphere
impotence
incidental appendectomy
incisional hernia
incisional pain
incisional tenderness
incontinence
incontinent
increased AP diameter of chest
Inderal
indistinguishable
indurated stomach
induration
indwelling catheter

indwelling Foley catheter
infected eczema
infectious process
infiltrate
infiltrative process
inflammatory bowel disease
inflammatory ulceration
inflatable penile prosthesis
infraclavicular
infragluteal fold
infrahilar region
inframammary region
infrapatellar tendon
inguinal area
inguinal hernia
inhalant therapy
injection therapy
in regard to
inspiration
inspiratory rhonchi
intact pulses
intellectual deficit
intellectually deficient
intensity
intensive physical therapy
interdental wires
intermittent
intermittent dilation of urethra
intermittent traction
internal compression screw fixation of hip
internal jugular vein
internal urethrotomy
interstitial edema
intertrochanteric fracture
interventricular conduction abnormality
intoxicated
intra-abdominal fluid
intra-abdominal liposarcomas
intra-articular space of elbow
intralesional steroids
intramuscularly
intranasal exam
intraocular pressure
intraoperative radiation
intrathecal methotrexate
intrauterine pregnancy
intravenous fluids
intravenous nitroglycerin drip
introitus
intubated
in vitro PHA (phytohemagglutinin) response
iodoform gauze
IPPB (intermittent positive pressure breathing)
iron
iron-binding capacity
iron deficiency
irregularity
irregularly irregular
irrigation and debridement
irritability
irritable bowel syndrome
irritants
ischemic cardiomyopathy
ischial fracture
isopropyl alcohol
Isordil
IUPC (intrauterine pressure catheter)
IV (intravenous)
IV access
IV drug abuse
IV hydration
IV load
IVP (intravenous pyelogram)
IVP dye
J, j
Jackson-Pratt drain
jaundice
jejunoileal bypass
JVD (jugular venous distention)
K, k
Kaopectate
KCl (potassium chloride)
K-Dur
Keflex
Keftabs
Kernig�s sign
ketoconazole
ketones
kg (kilogram)
kidney stone

kilo (kilogram)
klebsiella organism
knee jerk
KPT laser
KS (Kaposi sarcoma) lesions
KUB film
kyphotic chest
L, l
L (liter)
lab (laboratory)
labor and delivery
laceration
lactobacillus organism
LAD (left anterior descending)
laminectomy
Lanoxin
LAP (leukocyte alkaline phosphatase)
laparoscopic tubal cautery
laparoscopy
large-based quad cane
laryngeal mirrors
laser therapy
Lasix
lateral aspect
lateral joint line
lateral malleolar fragments
lateral malleolus
lateral patellar release
LDH (lactic dehydrogenase)
LDH enzymes
LDH1 isoenzyme
LDH2 isoenzyme
leakage
lecithin
LeFort I maxillary osteotomy
left shift
leg-length inequality
leiomyomas
lens implant
lesion
lethargic
leukocyte alkaline phosphatase (LAP)
leukocytes
leukocytosis
Librium
lidocaine
light-headed
light-headedness
light massage
light reflex
linear excoriations
lipase
lipodystrophy
liquid diet
liquid feedings
liquid stool
Listerine
live-donor liver transplant
liver enzymes
liver function studies
liver laceration
liver profile
liver span
LMP (last menstrual period)
local anesthesia
localizing
lochia
long-acting
longitudinal
long-standing
loose stools
Lopressor
Loprox
loss of testicle
Lotrimin cream
lower lobe infiltrate
lower lobe pneumonia
lower transverse incision
low-grade temperature
low-running glucose postpartum
low-salt diet
low-sodium diet
low voltage
low-voltage changes
LP (lumbar puncture)
L10 protocol
lucid
lumbar puncture (LP)
lumbar radiculitis
lung malignancy
lung scan

Lupron therapy
LUTS (lower urinary tract syndrome)
lymphadenitis
lymphadenopathy
lymphoblastic malignant lymphoma
lymphocyte count
lymphocytosis
lymphoma
lymph nodes
lymphs (lymphocytes)
lysis of adhesions
lysozyme
�lytes� (slang for electrolytes)
M, m
MAC (Mycobacterium avium complex)

macrocytic anemia
macrocytosis
Macrodantin
macromastia
macular
Maisonneuve-type ankle injury
malaise
malfunctioning penile prosthesis
malignant fibrous histiocytoma
malignant melanoma
malnourished
malnutrition
malunion
mammaplasty
mammography
mandibular prognathism
mandibular sagittal split osteotomy
markedly obese
masked appendicitis
massively obese
mastodynia
Maxair metered-dose inhaler
maxillary hypoplasia
maxillofacial bones
maxillofacial skeletal malformation
Maxzide
MB band
McBurney point
mcg (microgram)
McMurray sign
MCV (mean corpuscular volume)

MD (medical doctor)
Meals on Wheels
meat slicer
meatus
meconium
medial aspect of knee
medial meniscectomy
median nerve distribution
mediastinal hematoma
medical psychiatric unit
mediolateral
meds (medications)
Mefoxin
Megace
megaly
melena
melenic heme-positive stool
melenic stool
menarche
meningioma
meningitis
meniscal tear
meniscectomy
menometrorrhagia
menopause
menorrhagia
menses
mental retardation
mEq (milliequivalent)
mesenteric lymphadenopathy
mesothelioma of peritoneal cavity
metabolic derangements
metabolic encephalopathy
�metacytes� (metamyelocytes)
Metamucil
metamyelocytes (not metacytes)
metastasis (pl. metastases)
metastatic
metastatic melanoma of axilla
methadone
methotrexate
mg (milligram)
mg/dL (milligrams per deciliter)
mg/kg (milligrams per kilogram)
mg/m2 (milligrams per meter squared)

mg/mL (milligrams per milliliter)
MI (myocardial infarction)
microcytic indices
microdiskectomy at L5-S1
microgram (mcg)
microhematuria
Micro-K
midabdominal pain
mid calf
midesophagus
midline episiotomy
midline incision
midline shift
midshaft
midsystolic click
migraine headache
milky white discharge with foul odor
milligrams per meter squared (mg/m2)
millimeters per mercury (mmHg, mm Hg)
Minipress
mist tent
mitral anulus
mitral regurgitation
mitral stenosis
mitral valve prolapse
mitral valve prolapse murmur
mitral valve regurgitation
mixed flora
mixed-flora inflammatory dermatitis
mL (milliliter)
mL/h (milliliters per hour)
mm (millimeter)
mmHG, mm Hg (millimeters of mercury)
monilial esophagitis
Monistat cream
Monocid
mononucleosis
monos (monocytes)
mono (mononucleosis) test
morbid obesity
morphine
morphine infusional therapy
motor deficit
motor function
motor vehicle accident
Motrin
mouth rinse
moving bowels
MRI scan
mucosal atrophy
mucosal lesions
mucus plug
MUGA scan
multi-infarct dementia
multiparity
multiple adhesions
multiple myeloma
multivitamin
murmur, gallop, or rub
murmur, gallop, rub, or click
muscle relaxant
myalgia
Mycelex
Mycelex troches
Mycostatin oral suspension
myelocytes
myelofibrosis
myelogram
myeloma
myocardial biopsy
myocardial infarction
myocardial injury
myocardial morphology
myomata uteri
N, n
nadir
nafcillin
narcotics dependence
naris (pl. nares)
nasal abscess
nasal discharge
nasal dorsum
nasal oxygen
nasal polyp
nasal trauma
nasal vestibule
nasal vestibulitis
nasogastric tube
nasopharyngeal drainage
Naughton protocol
nausea

nauseated
neck vein distention
needle-nose wire cutters
Neisseria meningitidis
neoplasm
neoplastic process
Neosporin
nephrectomy
nephrogram effect
nephrolithiasis
nephrolithotomy
nephrosclerosis
nerve root
neuro (neurologic)
neuro checks
neurodegenerative disorder
neurodiagnostic evaluation
neuroimaging
neurologic deficits
neuropathy of extremities
neuro screen
neurovascular bundle
neurovascular compromise
neurovascular status of extremity
nevus flammeus
NG (nasogastric)
NG suction
NG tube
ng/mL (nanogram per milliliter)
Nicorette gum
nicotine abuse
Nitro-Bid
nitroglycerin
Nizoral (ketoconazole)
no axis deviation
nocturia
nodes
nodular excrescences
nodularity
noncomedogenic makeup products
nondiaphoretic
nondisplaced femoral neck fracture
nondistended
nonerythematous
nonfocal neurological exam
nonfunctional testicle
nonhealing fistula
nonicteric
noninvasive
nonpliable
nonprogression
nonreactive RPR
nonrebreather mask
nonreducible
nonresponsive
nonspecific changes
nonsteroidal anti-inflammatory agent therapy
nonstress tests
nontoxic-appearing
nonunion
nonweightbearing
normal sinus rhythm
normal-sized heart
normal-sized uterus
normal spontaneous delivery
normal vaginal delivery
normoactive bowel sounds
normocephalic
Novocain
Novolin
NPH insulin
n.p.o. (nothing by mouth)

nuchal rigidity
nucleated RBCs
numbness in feet
Nyquil
nystagmus
O, o
O2, O2 (oxygen)
OA (occipitoanterior) position
obese abdomen
obstructive uropathy
occiput
occlusive prostate
occult
occupational therapist
Ocean nasal spray
off-work status
olecranon
oozing
open grade 2 femur fracture

open lung biopsy
open reduction and plate fixation
open reduction-internal fixation
O positive
OR (operating room)
oral cavity
oral contraceptives
oral hygiene
oral lesions
oral mucosa
oral suspension
orchiopexy
organic impotence
Organidin
organomegaly
oriented x3 (to person, place, and time)
oropharynx
Ortho-Novum
orthopnea
orthostatic
os (cervical os)
osteoarthritis
osteomyelitis of distal calcaneus
osteoporosis
otitis media
outlying
ova and parasites
ovarian carcinoma
overexpansion of lungs
oxycodone
Oxy 10
P, p
PA (posteroanterior)
PA (pulmonary artery) pressure
pacemaker implant
packed red blood cells
packed spleen
palate
palatoplasty
paleness of conjunctivae
palliative treatment
pallid skin
palpable
palpable pulses
palpebral fissure
palpitations
pancreatic cancer
pancreatic injury
pancreatic mass
pancreatitis
P&A (percussion and auscultation)
Pap (Papanicolaou) smear
papilledema
papular lesions
papule
para
para 3, 2-0-1-2 (3 pregnancies, 2 term infants; 0
premature, 1 abortion, and 2 live births)
paradox
parameter
paranoia
paranoid
paratracheal mass
paratracheal region
parenteral
paresthesia
parietal scalp
parkinsonism
partial gastrectomy with vagotomy
partial wound closure
passage of gas
passing gas from rectum
passing water
passively
patella (pl. patellae)
patellar crepitus
patellar passive mobilization
patellar snap
patent
patent nares
patent processus vaginalis
pathogens
patulous anus
pCO2, PCO2, PCO2 (partial pressure of carbon
dioxide)
PCP (Pneumocystis carinii pneumonia)
PCU (progressive care unit)
PDA (posterior descending artery)
pedal edema
pedal pulses
pediatric endocrinology

pelvic adhesions phallus
pelvic cuff cellulitis pharyngeal mucosa
pelvic endometriosis pharyngeal soft tissue swelling
pelvic examination pharyngitis
pelvic mass pharynx
pelvic relaxation Phenergan
pendulous breasts phlegmon
penicillin VK (penicillin V potassium) photophobia
penile implant pinch test
penile lesion pinprick
penile prosthesis piperacillin
penis Pitocin
pen VK (penicillin V potassium) pitting edema
Pepcid placebo
peptic ulcer disease placenta
Percocet plain film of abdomen
percussion and auscultation plantar periosteal reaction
percussion note plaque
percutaneous needle aspirate plaque on dorsum of penis in distal shaft
perianal area plasma volume
pericardial effusion platelet aggregate studies
pericardial reflection platelet count
perineal biopsy platelet function defect
perineal tear platelets
perinephric abscess pleural effusion
perineum pleurisy
perioperative pleuritic
peripheral edema PMNs (polymorphonuclear leukocytes)
peripheral pulses PMS (premenstrual syndrome)
peripheral vascular insufficiency PND (paroxysmal nocturnal dyspnea)
peritonitis pneumocystis pneumonia
periumbilical pain pneumonia
peroneal nerve pneumopericardium
peroxide pneumoperitoneum
perpendicular plate of ethmoids pO2 , PO2, PO2
PERRL (pupils equal, round, react to light) p.o. (per os, by mouth)
PERRLA (pupils equal, round, react to light and p.o. intake
accommodation) polyarthritis
Persantine polycentric knee hinge
personality disorder polyclonal gammopathy
petechiae polydipsia
petroclival cerebellopontine angle polys (polymorphonuclear leukocytes)
Peyronie disease of penis Polysporin ointment
Peyronie plaque on penis polyuria
pH (hydrogen ion concentration) P1, 0-0-1
PHA (phytohemagglutinin) response poor feeding pattern

poor prep
popliteal flexion crease
popliteal pulses
popping knee
popping sensations in knee
portal vein
port of entry
Portuguese
positive bowel sounds
postchemotherapy radiation
posterior fossa
posterior horn of medial meniscus tear
posterior malleolar-lateral malleolar fracture
posterior malleolus
posterolateral osteophyte
posthospital followup
postinfarction
postinflammatory scarring
postmaturity
postmyelogram CT scan
postop (postoperative)
postoperative course
postpartal instructions
postpartum
postpartum care
postulate
postvoid residual
Potaba
potassium (KCl)
potassium permanganate soaks
potassium supplement
precordium
prednisone
pregnancy-induced hypertension
premature atrial beats
premature atrial complex
premature labor
premature ventricular depolarizations
premenstrual syndrome
prenatal care
prenatal course
prenatal vitamins
preop (preoperative)
preoperative
prepatellar bursa
prepatellar pain
presacral area
pretibial edema
primary bronchogenic carcinoma with bilateral
dissemination
Primatene inhaler
primigravida
principal diagnosis
PR interval
p.r.n. (as needed)

pro time (prothrombin time)
Procardia
Procardia XL
processus vaginalis
productive cough
prolonged labor
prolonged nutrition support
prominence
prominent bone spike
promyelocyte
prophylactic antibiotics
prophylactically
prophylaxis
propranolol
prostate
prostate biopsy
prostatism
prostatitis
prosthetic arthroplasty
proteinuria
Proventil MDI (metered-dose inhaler)
proximal diverting colostomy
pruritic rash
pruritus
PSA (prostate-specific antigen) test
pseudomonas
Pseudomonas aeruginosa
pseudophakia
psoriasis
psychotic depression
PT (physical therapy)
PT (prothrombin time)
PTCA (percutaneous transluminal coronary
angioplasty)
PTs (posterior tibials [pulses])
PTT (partial thromboplastic time)
pubic rami fracture

pubic ramus (pl. rami)
pudendal anesthesia
puffs from inhaler
pulmonary disease
pulmonary embolism
pulmonary fibrosis
pulmonary function studies
pulmonary nodes
pump device
punch biopsy
purulent discharge
pus
pustule
P waves
pyelolithotomy
pyelonephritis
pyloric channel ulcer
pyramidal tract
Pyridium
pyuria
Q, q
q. (each; every)
q.a.m. (every morning)
q. day (daily; every day)
q.i.d. (4 times a day)
q.p.m. (every evening)
QRS
QT prolongation
q.12 h. (every 12 hours)
quad cane
quadrant
quadriceps
quadriceps program
quadriplegia
quadruple
quinidine
quinine
quinolones
R, r
radial nerve distribution

radial pulse
radiating through to the back
radiation therapy
radical prostatectomy
radiculopathy
rads
rainbow coverage
rales
ramus intermedius
range of motion
rapid strep
RBC, RBCs (red blood cells)
RBC/hpf (red blood cells per high-power field)
reactive lymph nodes
reactive lymphocytosis
rebound
rectal bleeding
rectal exam (examination)
rectal temperature
recumbent position
recur
recurrence of hernia
recurrent ileus
recurrent vaginitis
recurrent vomiting
red cells
red reflex
reducible hiatal hernia
reduction mammaplasty
referable
reflex
reflex hammer strike
reform the urethral stricture
refractory bacterial vaginosis
refractory to treatment
regime
regimen
Reglan
regressed
rehab evaluation
remarkably unremarkable
renal failure
renal insufficiency
renal pelvis
reopening of the chest
resection
residual
resonant
respiratory excursions

respiratory flora
respiratory sounds
respiratory tract infection
restaging
resuscitated
Retin-A gel
retinal contour
retinal detachment
retinal tear
retinopathy
retrograde pyelogram
retrograde urethrogram
retroperitoneal lymphadenopathy
revascularization
Reye syndrome
rheumatic fever
rhinoplasty
rhinorrhea
rhonchi
right-hand-dominant
rigidity
rigorous bowel program
Robitussin A-C
Robitussin-DM
Rocephin
rods in back
Romberg
rombergism
Rondec
room air
rotation flap
Rotazyme
rotund abdomen
Roux-en-Y hepaticojejunostomy
RPR (rapid plasma reagin) test for syphilis
RU (resin uptake)
rubella immune
rubor
rubs
rupture of membranes
ruptured vesicles
Russell traction
Rx (prescription)
S, s
S1, S2, S3, S4 (or S1, S2, S3, S4) (or (1st, 2nd,
3rd, 4th heart sounds)
saddlebag deformity
salicylate level
salpingo-oophorectomy
salt restriction
satellite lesion
satiety
scalp monitor
scant discharge
scar tissue over dorsum of penis
scarring
sciatica due to herniated disk
sclera (pl. sclerae)
sclerosis
scrotal exploration
scrotal support
scrotum
scrotum transilluminates
2nd degree midline episiotomy
secondary diagnosis
secretions
secretions from nipple
secretory endometrium
sedimentation rate
sed rate (sedimentation rate)
segs (segmented neutrophils)
seizure activity
seizure disorder
seminal vesicles
senile emphysema
sensation intact
sensitivity testing
sensorimotor
sensory function
sepsis
septal deviation
septic
septoplasty
septorhinoplasty
Septra DS (double-strength)
Septra suspension

sequela (pl. sequelae) sludge in gallbladder
serial CT scans SMAC (�smack�) (Sequential Multiple
serial films Analyzer Computer)
serial sonograms SMAC analyzer
serology SMAC profile
serology nonreactive small-based quad cane
serous otitis small-bowel follow-through
serum complement level small-bowel ileus
serum cryptococcal antigen small-bowel obstruction
serum iron-binding capacity SMA-16
serum sodium level SOAP (subjective, objective, assessment, plan)
severity Social Services
sexual impotence sodium
sexual intercourse soft tissue closure
SGOT (now AST) Solu-Cortef
shaking chills sonogram
shave biopsy spasmodic croup
shift to the left Spectazole cream
shin splints speculum
shivering Speech Pathology
short stature sphincter tone
short leg cast (not short-leg) sphincterotomy
shortness of breath sphygmomanometer
shotty adenopathy spike a fever
shotty cervical adenopathy spike a temperature
shotty cervical lymphadenopathy spinal anesthesia
shoulder instability spinal compression fracture
sigmoid diverticulosis spinal stenosis
sigmoidoscopic examination spinal tap
sigmoidoscopy spinning-type sensation
�silent� pyelonephritis spinous process
single-vessel disease spleen laceration
sinusitis spleen tip
sinus rhythm splenic flexure
sit-to-supine transfer splinting
sitz bath split-thickness skin grafting
Skene gland spondylitic changes
skilled nursing facility spontaneous cry
skin staples spontaneous delivery
skin traction spontaneous, vaginal, vertex
skin turgor spotting
sleep apnea sputum culture
sliding hiatal hernia sputum for culture and sensitivity
sliding scale stabilization
slit-lamp exam stabs (stab cells)
slowing of EEG waves stage of labor

staghorn calculus (pl. calculi) subpulmonic fluid
standby assistance suction-assisted lipectomy
ST and T-wave abnormalities suctioned
ST and T-wave changes suction lipectomy
staph (staphylococcus) sulfa
staph A sulfa drugs
staphylococcus (pl. staphylococci) summation gallop
Staphylococcus aureus coagulase-positive sump
station (-2, -1, 0, +1) superimposed
station of fetus within pelvic cavity superior vena cava
status post supine-to-sit transfers
status post amputation supple
status post mastectomy for adenocarcinoma supplemental iron and vitamins
STDs (sexually transmitted diseases) suppository
Steinmann pin supraclavicular adenopathy
stenosis supraclavicular fossa
stent placement supraclavicular region
stereotactic radiosurgery suprapatellar area
steroid therapy suprapubic
steroids suprapubic cystotomy
stimulants supraventricular tachycardia
stippling Surfak for stool softening
stomach contents surgical intervention
stool for occult blood surgically absent cervix and uterus
stool for ova and parasites and culture Surmontil
stool softener suspicious lesion
straddling suture line
strengthening exercises Swan-Ganz catheter
strep (streptococcus) swimmer�s ears
streptococcus (pl. streptococci) symmetric reflexes
Streptococcus faecalis symmetrical
stroke sympathectomy
ST segment symptom complex
ST-segment change symptomatic
ST-segment elevation symptomatically improved
ST-T abnormalities symptomatology
ST-T wave abnormalities syncope
subcapsular cataract syndesmotic screws
subclavian area Synthroid
subclavian vein syphilis serology
subcu (subcutaneous) systemic arterial hypertension
subcutaneous abscess systolic ejection murmur
subcutaneous metastases systolic murmur
subdural hematoma systolic pressure
submucous resection of septum

T, t
T3, T3 (triiodothyronine) test

T4, T4 (thyroxine) test
T4/T8 ratio
tachypnea
tachypneic
Tagamet
TAH-BSO (total abdominal hysterectomy,
bilateral salpingo-oophorectomy)
takedown of jejunoileal bypass
takeoff
tapered
TB (tuberculosis)
T-cell panel
T-cell status
T cells
TED (thromboembolic disease)
T.E.D. hose (trademarked)

temperature spike
temperaturewise
105 (�10 to the 5th�) colony count
tendinitis
TENS (transcutaneous electrical nerve
stimulation)
TENS unit
term intrauterine pregnancy
testes descended
testicle
testicular pain
theophylline level
Theragran-M
therapeutic range
thiamine
thiazide diuretics
thirsty
thoracic bleeding
thoracic incision
3-vessel cord
3-vessel disease
thrills
throat lozenge
thrombophlebitis
thrombosis
thrush
thyroid function test
thyroidectomy
thyromegaly
tibia
tibialis posterior pulses
t.i.d. (3 times daily)

Tigan
times (x)
Timoptic
tinea pedis
tingling sensation
titers
TM, TMs (tympanic membrane[s])
TNTC (too-numerous-to-count) white cells
Tobramycin
toe web infection
tonsillar enlargement
tonsillar hypertrophy
tonsillectomy and adenoidectomy
too-numerous-to-count (TNTC) white cells
topically
topical Polysporin ointment
torsion
torsion of testicle
total abdominal hysterectomy and bilateral
salpingo-oophorectomy
total protein
toxic baby
toxicity
trabeculated bladder
trabeculectomy of eye
trachea midline
trace amount of bile
trace bacteria
trace edema
trace for protein
tracheostomy
tract of ureter
traction
tranquilizers
transbronchial lung biopsy
transdermal continuous-release patch
transfer training
transfixion screw
transfuse, transfused
transfusion
transient hypoglycemia in newborn
transient ischemic attack
transilluminates U, u
transitional cell carcinoma of bladder UA (urinalysis)
transrectal biopsy UGI (upper GI) bleed
transrectal ultrasonography ulnar nerve distribution
transrectal ultrasound ulnar nerve involvement of elbow
transurethral resection of bladder tumor ulnar pulse
transverse incision ultrasound
Tranxene umbilicus
trauma uncomplicated pregnancy
trauma bay undesired fertility
traumatic arthritis of knee undetermined
traumatic brain damage unilateral
treatment modalities unresectable tumor
Trental unstable angina
trichlormethiazide updraft therapy
trichomonas organism upper airway noise
trigeminal neuralgia upper outer quadrant of breast
triglycerides upper pole nephrectomy
Trilisate upper respiratory airway narrowing
trimester upper respiratory infection (URI)
triple-vessel coronary artery bypass graft upright film of abdomen
trochanter up-to-date
trochlear lesion ureteral colic
TSH (thyroid stimulating hormone) ureteral orifice
tubal ligation ureteral stent
tube gastrostomy ureteral stone with obstruction
tube gauze ureteral stone, passed
Tubegauz (trademark) ureteroscopy
tube graft urethral reconstruction urethra dilated
tuberous sclerosis urethral gland
TUR (transurethral resection) urethral meatus
turgor urethral stricture
TURP (transurethral resection of prostate) urethral stricture disease
T-wave changes urge incontinence
T-wave inversion URI (upper respiratory infection)
22-French Foley catheter urinalysis (not urine analysis)
2-hour postprandial glucose screen urinary amylase
Tylenol urinary clot retention
Tylenol No. 3 urinary flow rate
Tylenol with Codeine elixir urinary frequency
Tylenol with Codeine No. 3 urinary incontinence
Tylox urinary retention
tympanic membranes urinary stream
tympanometry urinary tract infection
urine collection bag (wee bag)
urine culture

urine stress incontinence
urine Wellcogen test
uterine prolapse
uterus
UTI (urinary tract infection)
UV (ureterovesical) junction
uvula
V, v
vaginal bleeding
vaginal discharge
vaginal hysterectomy
vaginal intercourse
vaginal introitus
vaginal pruritus
vaginal vault
vagotomy
vague
Valium
valvular heart disease
varicocele
varicosities
varus knee
vascular insufficiency
vascular refill
vastus medialis obliquus (VMA) muscle
venous insufficiency
ventilator dependence
Ventolin inhaler
ventricular angiography
ventricular ejection fraction
ventricular fibrillation (VF)
ventricular-peritoneal or ventriculoperitoneal
shunt
ventricular response
ventricular rhythm
ventricular tachycardia
ventriculopleural shunt
verapamil
verbal cues
vertex fetus
vertex OA presentation
vertex presentation
vertical skin incision
vertigo
vesicle (pl. vesicles)
vestibule
VF (ventricular fibrillation)
viable
viable term infant
Vicks Formula
Vicodin
vincristine
viral etiology
viral exanthem
viral gastroenteritis
viral pharyngitis
viral syndrome
viral type of symptomatology
visual acuity
visual changes
visual fields by confrontation
vital signs
vitamin E therapy
vitreous body
void a good stream
voiding clear urine
volar aspect
voltage
vomiting
vomiting x1 (times one)
vulva
W, w
water-bottle kidney
watts
waxed and waned
WBC, WBCs (white blood [cell] count)
WBC/hpf (white blood cells per high-power
field)
weaning off the ventilator
wedge
wee bag (urine collection bag)
weeping dermatitis
weightbearing
well-baby check
Wellcogen test
Wernicke area
Western blot test
wet prep
wheeze
wheezing

white blood cell count
white cell casts
whitish mucus
wide local excision
widened ankle mortise
widening of ankle mortise
WNL (within normal limits)
workup
wound care
wound infection
X, x
x (by, as in 1 x 2 x 3 cm)
x (times, as in x3 days; oriented x3)
Xanax
Xylocaine
Xylocaine local anesthetic
Y, y
yeast
yeast infections
yellow jaundice
Z, z
Zantac
0 (�zero�) station
zidovudine (new name of AZT)
Zinacef
Zovirax ointment

Index to Medical Reports
acne, Derm/Plas #5
adult respiratory distress syndrome (ARDS), Cardio #10, Cardio #13
agoraphobia, Neuro/Psych #8
AIDS, Hem-Onc-Immuno #13
anal prolapse, GI #12
anemia, Hem-Onc-Immuno #7
angina, Cardio #19
appendicitis, GI #9, GI #17, GI #19
arthroscopy, Ortho #12
asthma, Peds #5
atrial fibrillation, Cardio #5, Cardio #14, Cardio #18
atrial flutter post cardioversion, Cardio #20
back pain, Ortho #18; back and leg pain, Ortho #29
below-knee amputation, Ortho #5
bile leak, GI #20
bipolar disorder, Neuro/Psych #21
bladder outlet obstruction, GU #8
bladder tumor, GU #5
blind eye, HEENT #12; HEENT #14
bone marrow disease, Hem-Onc-Immuno #14
brain infarct, Neuro/Psych #5, Neuro/Psych #9, Neuro/Psych #18
brain tumor, Hem-Onc-Immuno #12
breasts, Derm/Plas #7
bronchitis, Cardio #1, Cardio #2, Cardio #9, Cardio #11
bronchogenic carcinoma, Hem-Onc-Immuno #11
bursitis, Ortho #7
carbon monoxide poisoning, Peds #14
carcinoma, Hem-Onc-Immuno #1, Hem-Onc-Immuno #3, Hem-Onc-Immuno #6,

Hem-Onc-Immuno #11, Hem-Onc-Immuno #12, Ob-Gyn #1
cardiac death, Cardio #6, Cardio #10, Cardio #11
cardiomyopathy, Cardio #15, Cardio #23
cataract, HEENT #15
cellulitis, Derm/Plas #8; HEENT #11
cerebrovascular accident, Neuro/Psych #15
cervical dysplasia, Ob-Gyn #15
cesarean section, Ob-Gyn #11, Ob-Gyn #18, Peds #11
cholecystitis, GI #7, GI #10
chronic fatigue syndrome, Hem-Onc-Immuno #5
chronic obstructive pulmonary disease (COPD), Cardio #5, Cardio #9, Cardio #21,
Cardio #23
cleft lip and palate repair, Derm/Plas #13

Code Blue, Cardio #6

colitis, GI #14
colon carcinoma, Hem-Onc-Immuno #6
comatose, Neuro/Psych #12
congestive heart failure (CHF), Cardio #5, Cardio #7, Cardio #11
coronary artery bypass grafting, Cardio #19
Crohn�s disease, GI #11
croup, Peds #2
death, Cardio #6, Cardio #11

decelerations, Ob-Gyn #9
dementia, Neuro/Psych #10
dermatitis, Derm/Plas #4, Peds #8
diabetes mellitus, Peds #4
disk herniation, Ortho #24
dysmenorrhea, Ob-Gyn #2
dyspnea, Cardio #8
electrocardiographic rhythm strip, Cardio #22

electroencephalogram, Neuro/Psych #16, Neuro/Psych #17
emphysema, Cardio #16
emphysematous gallbladder, GI #6
encephalopathy, Neuro/Psych #13
epistaxis, HEENT #10
esophagogastroduodenoscopy, GI #13
fecal impaction, GI #5
fever, Peds #13
finger laceration, Derm/Plas #1
fistula, GI #11
fontanel, Peds #9, Peds #12, Peds #13
fracture, Ortho #9, Ortho #11, Ortho #21, Ortho #23, Ortho #25, Ortho #28, Ortho
#30
gammopathy, Cardio #12

gardnerella infection, Ob-Gyn #6
gastrointestinal bleed, GI #15, GI #16
glaucoma, HEENT #16
graft, Derm/Plas #9
gunshot wound with fractures, Ortho #20
head injury, Neuro/Psych #12, Peds #3
headache, Neuro/Psych #2, Neuro/Psych #7
hearing test, HEENT #4
heart disease, Cardio #14, Cardio #19, Cardio #24
heel pain, Ortho #3
hemorrhoids, GI #12
hernia, GU #1, GU #6
hip pain, Ortho #22

hip pin removal, Ortho #14
histiocytoma, Derm/Plas #12
HIV, Hem-Onc-Immuno #2
hydrocephalus, Neuro/Psych #11, Neuro/Psych #20
hypertension, Ob-Gyn #20
hypoglycemia in newborn, Peds #6
hysterectomy, Ob-Gyn #5, Ob-Gyn #19
ileus, GI #4
irritable bowel syndrome, GI #1
leg injury, Ortho #15

leukemia, Hem-Onc-Immuno #15
lip lesion, Derm/Plas #3
lipectomy, Derm/Plas #2
liposarcoma, Hem-Onc-Immuno #3
liver laceration, GI #18
lymphadenitis, Peds #7
maxillofacial malformations, Derm/Plas #11

melanoma, Hem-Onc-Immuno #1
meniscal injury, Ortho #8
menorrhagia, Ob-Gyn #17
mental status alteration, Neuro/Psych #20
mesothelioma, Hem-Onc-Immuno #9
mononucleosis, Hem-Onc-Immuno #8
Mycobacterium avium complex, Hem-Onc-Immuno #2
myocardial infarction, Cardio #17, Cardio #21
neuralgia, Neuro/Psych #14

nevus, Derm/Plas #6
osteomyelitis, Ortho #1
otitis media, HEENT #1, HEENT #6, HEENT #9, Peds #1, Peds #7, Peds #8
pain: back, Ortho #18; back and leg, Ortho #29; hip, Ortho #22; knee, Ortho #6,
#13
pancreatitis, GI #3, GI #8
Pap smear, Ob-Gyn #3
pemphigoid, Derm/Plas #10
penile prosthesis, GU #2
perinephric abscess, GU #11
peripheral vascular disease, Cardio #3
Peyronie�s disease, GU #13
pharyngitis, Derm/Plas #5, HEENT #5, Peds #7
pleural effusion, Cardio #12
pneumonia, Cardio #7

premature labor, Ob-Gyn # 4
prostate, GU #10, Hem-Onc-Immuno #4
psychiatric evaluation, Neuro/Psych #19
pulmonary chest pain, Cardio #25
pulmonary edema, Cardio #10
pulmonary fibrosis, Cardio #23
pyelonephritis, GU #9
radiculopathy, Ortho #19

renal insufficiency, GU #15
retinal tear/cryopexy, HEENT #13
rhinitis, HEENT #3
schizophrenia, Neuro/Psych #1
schwannoma, Neuro/Psych #6
sciatica, Ortho #16
sepsis, Cardio #10, Peds #9, Peds #10, Peds #13
septal deviation, HEENT #8
shin splints, Ortho #4
short stature, Peds #1
shoulder instability, Ortho #2
sinusitis, HEENT #2
slurring of speech, Neuro/Psych #13
sprain of cervical and lumbar spine, Ortho #10
staghorn calculus, GU #16
stone, GU #4, GU #7
testicular torsion, GU #17

tonsillectomy and adenoidectomy, HEENT #7
tracheostomy, Cardio #4
ulcer disease, GI #7, GI #15

upper respiratory infection, Cardio #2
urethral stricture, GU #14
urinary tract infection, GU #3
uterine myomata, Ob-Gyn #14
vaginal delivery, Ob-Gyn #8, Ob-Gyn #10, Ob-Gyn #13, Ob-Gyn #16, Ob-Gyn #20
vaginosis, Ob-Gyn #7
ventricular fibrillation, Cardio #24
ventricular-peritoneal shunt, Neuro/Psych #3
ventriculopleural shunt malfunction, Neuro/Psych #4
viral infection, Peds #9
vomiting, GI #2, Peds #13
walking and mobility trouble, Ortho #26, Ortho #27

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Medical Notes

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252 Book reviews

valuable and beautifully illustrated work, very adequately

The book is highly recommended to radiologists in

Concepts of Human Anatomy and Physiology, 4th

As a retired surgeon teaching preclinical anatomy in Britain

This American book shows how we should do it. With

No, it does not have lists of relations of structures and

This elegant and informative book is devoted to sex

page table devoted to famous reproductive biologists

Chapter 2, on Mechanisms of Sex Determination, is

Chapter 3 deals with differentiation of the gonads and

Chapters 5-7 can be considered together since they deal

Chapter 8 differs from the last three in that it discusses sex

Combination of individual atoms, molecules, polypeptides, cells in human body, is

INITIAL OFFICE EVALUATION (2:30)

PAST MEDICAL HISTORY4

�2005, Health Professions Institute80http://www.hpisum.com

�2005, Health Professions Institute81http://www.hpisum.com

OFFICE NOTE (2:00)

1 Insert or for proper usage.

�2005, Health Professions Institute82http://www.hpisum.com

OFFICE NOTE (3:30)

EXAMINATION THIS DATE

�2005, Health Professions Institute83http://www.hpisum.com

�2005, Health Professions Institute84http://www.hpisum.com

PREOPERATIVE NOTE (0:30)

The patient is a 39-year-old female who underwent clipping of a cerebral aneurysm.

�2005, Health Professions Institute85http://www.hpisum.com

HISTORY AND PHYSICAL EXAMINATION (1:30)

HISTORY OF PRESENT ILLNESS

�2005, Health Professions Institute86http://www.hpisum.com

�2005, Health Professions Institute87http://www.hpisum.com

EMERGENCY DEPARTMENT REPORT (2:00)

HISTORY OF PRESENT ILLNESS

EMERGENCY ROOM COURSE

1 Headings are added for consistency in format.

Expand unacceptable brief forms.

�2005, Health Professions Institute88http://www.hpisum.com

DISCHARGE SUMMARY (3:00)

1. Right lower lobe pneumonia secondary to pseudomonas.

1 Alternative: Alzheimer. The use of the possessive form of eponyms is acceptable

�2005, Health Professions Institute90http://www.hpisum.com

DISCHARGE SUMMARY (3:00)

REASON FOR ADMISSION

�2005, Health Professions Institute91http://www.hpisum.com

�2005, Health Professions Institute92http://www.hpisum.com

DISCHARGE SUMMARY (1:30)

HISTORY AND PHYSICAL EXAMINATION

1. Acute bronchitis with respiratory distress.

1 Headings are added for consistency in format.

DISCHARGE SUMMARY (2:00)

1 Capitalize a department name that is referred to as an entity.

�2005, Health Professions Institute94http://www.hpisum.com

DISCHARGE SUMMARY (1:30)

REASON FOR ADMISSION

1 Headings are added for consistency in format.

�2005, Health Professions Institute95http://www.hpisum.com

PAST MEDICAL HISTORY

�2005, Health Professions Institute96http://www.hpisum.com

1. Right pleural effusion.

1. Patient should be on the following medications: Dilatrate 40 mg daily,15

DISCHARGE SUMMARY (2:00)