Medical Transcription
Dr. Adam’s dictation dated 04/03/08
Patients name: Diane G. Baron
D.O.B: 09/07/1935
Age: 72
Sex: Female
Subjective: Diane is here today with complaints of sinus symptoms, cough, there is a lot of pressure in her face, post nasal drainage. She denies any sore throat, no fever or chills. She states she’s coughing up quite a bit of white flam. She states at night sometimes she has to sit up, otherwise she starts coughing when she lies flat. She denies any night sweats; she is currently on combovent meter dose inhaler 4 puffs 4x a day. She has no longer utilized preventaliza phase.? Since hospitalization she does feel at times during the day time her chest feels tight and wheezy , she denies any further weight loss, the patient has a history of extensive small cell carcinoma, she recently completed six cycles of chemotherapy. She is in the process of getting bone scans and repeat cat scans metazisis. Patient denies any bone pain.
Objective: On physical examination she is a very pleasant female well known to myself. She is in no acute respitory distress, no chest wall retraction, and no audible wheezes.
HEEMT: Pupils are equal, round, and reactive to light and accommodation. Tm’s are clear, palpations to both maxillary sinus regions mimnumly tender. She does have perorbital edema in the suborbital regions apical? Are mildly adenitis without congestion?
Lung fields: She does have diffused rocking though out, no wheezing or rails. Cardiovascular regular abdomen, unremarkable extremities, no sciniousis or endemic, Nero-exam cognition appropriate.
Assessment:
1. Sinusitis 2. Bronchitis 3. Extensive small cell carcinoma lungs with possible metastasis
Plan:
1. We will go ahead and imparently treat patient with antibiotics. I gave her ten day dose viaxin 600mg B.I.D. I gave her Claritin-d 12 to take every twelve hours. She is to push water, vitamin c. I have her on some cough suppressant medication, my concern is whether or not this is more
Patients name: Diane G. Baron
D.O.B: 09/07/1935
Age: 72
Sex: Female
Subjective: Diane is here today with complaints of sinus symptoms, cough, there is a lot of pressure in her face, post nasal drainage. She denies any sore throat, no fever or chills. She states she’s coughing up quite a bit of white flam. She states at night sometimes she has to sit up, otherwise she starts coughing when she lies flat. She denies any night sweats; she is currently on combovent meter dose inhaler 4 puffs 4x a day. She has no longer utilized preventaliza phase.? Since hospitalization she does feel at times during the day time her chest feels tight and wheezy , she denies any further weight loss, the patient has a history of extensive small cell carcinoma, she recently completed six cycles of chemotherapy. She is in the process of getting bone scans and repeat cat scans metazisis. Patient denies any bone pain.
Objective: On physical examination she is a very pleasant female well known to myself. She is in no acute respitory distress, no chest wall retraction, and no audible wheezes.
HEEMT: Pupils are equal, round, and reactive to light and accommodation. Tm’s are clear, palpations to both maxillary sinus regions mimnumly tender. She does have perorbital edema in the suborbital regions apical? Are mildly adenitis without congestion?
Lung fields: She does have diffused rocking though out, no wheezing or rails. Cardiovascular regular abdomen, unremarkable extremities, no sciniousis or endemic, Nero-exam cognition appropriate.
Assessment:
1. Sinusitis 2. Bronchitis 3. Extensive small cell carcinoma lungs with possible metastasis
Plan:
1. We will go ahead and imparently treat patient with antibiotics. I gave her ten day dose viaxin 600mg B.I.D. I gave her Claritin-d 12 to take every twelve hours. She is to push water, vitamin c. I have her on some cough suppressant medication, my concern is whether or not this is more