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Assignment 9 - Medical Transcription
Beginning Medical Transcription (HLTH8131)
Loyalist College
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Report 13, Internal Medicine Clinic HPIP Note
Leon Medina, MD, dictating an Internal Medicine Clinic HPIP note on
Patient Name: Mary Fisher Lipscomb PCP: Rosemary Bumbak, MD
Patient ID: 013550 DOB: 10/5/---- Age: 63 Sex: Female
Date of Exam: 08/10/----
HISTORY: Patient is a 63- year-old white female with past history, significant for a total mastectomies TAH without BSO and a history of breast cancer who presents to the clinic in follow-up for bloating. The patient has been complaining of approximately 3 to 4 months of bloating in the upper middle abdominal region. The patient's symptoms continue to be unchanged from prior clinic visits over the last month. She states that she has had bloating at a baseline level that is mild present throughout the day; however it flares up immediately with a meal and lasts at this intensity for up to 2 hours. The symptoms are not associated with nausea, vomiting, early satiety, globus sensation, cough, gagging, regurgitation, or diarrhea. Patient continues to state, that the pain does not radiate anywhere. The patient states that she has always been constipated, requiring Metamucil to set herself to her goal bowel movements, of 2 to 3 times daily. The patient continues to report no change in the frequency of her stools and says that she has 1 to 2 well-formed brown stools for day. The patient denies recent weight loss, a personal or family history of gastrointestinal disorders, chest pain or shortness of breath. The patient continues to report a normal level of flatus, reports a normal colonoscopy 1 to 2 years ago. The patient will be getting her well-woman exam within the next month.
Patient was initially tried on empiric therapy with Protonix approximately 4 weeks ago without success. Most recently she stopped her Metamucil again without remission in her bloating.
Past history includes migraine headaches, preceded by visual aura, glaucoma, allergic conjunctivitis, osteopenia, nicotine dependence, insomnia on trazodone and Ambien, as well as COPD
Report 17, Pediatric Neurology Clinic Note
Hello Lyndon F. Talcott dictating. This is a pediatric neurology clinic note on
Patient Name: Grace Pereira PCP: Reed Phillips, MD
Patient ID: 017990 DOB: 06/24/---- Age: 7 Sex: Female
Date of Exam: 05/05/----
Reason for Visit: Follow-up of behavior. Patient accompanied by mother, records are unavailable.
HISTORY: Grace, a 7-year-old girl has a history of severe behavior problems, ADHD, bipolar disorder, borderline mental retardation, and significant past medical history of congenital hydrocephalus associated with myelination defect on MRI. Mother reports no new concerns, mother notes some brief improvement in the patient's impulsiveness and distractibility after starting Neurontin, however she feels that it is no longer effective. Since the last visit, blood tests were obtained and an MRI repeat MR spectroscopy. Also consultation with ophthalmology revealed normal hyperopia for age. Mother continues to express concern for the child's violent behavior, but notes that overall she is doing well in school. She has some difficulties with the arithmetic but she seems to be reading at or above grade level. Speech sometimes disconnected and nonsensical otherwise articulation is within normal limits. Patient continues to participate in special education at school, as well as anger management group sessions at school, at least weekly. She is managed by a psychiatrist for psychotropic medications and sees a child psychologist for behavioral management therapy.
MEDICATIONS: Abilify 2 mg p. b.i., Neurontin 100 mg p. b.i.
PHYSICAL EXAM: VITAL SIGNS: Weight is 23 kg, height is 118 cm, head circumference is 50 cm which is approximately the twenty-fifth to thirtieth percentile for age and is stable since last visit. Temperature 98 degrees Fahrenheit, heart rate 113, blood pressure 105/67, respirations 22, O 2 saturation 97% on room air.
GENERAL: Patient is awake and alert, pleasant and cooperative, well appearing in no cute distress, without dysmorphic features. HEENT: Normocephalic, atraumatic, pupils are equal, round and reactive to light and accommodation, extraocular movements intact, funduscopic exam normal.
Assignment 9 - Medical Transcription
Course: Beginning Medical Transcription (HLTH8131)
University: Loyalist College
