having been bitten while she was at work 2 days ago. Patient reports that a client bit her on the right upper arm while they were trying to sit him up in a chair for dinner. The patient reports that the skin was broken. She denies any fever‚ nausea‚ vomiting‚ neck pain‚ back pain‚ or abdominal pain. Vital signs: Temperature 36.5‚ pulse 90‚ respirations 18‚ blood pressure 113/64. She is alert and oriented. No acute distress. Patient reports that she has completed the hepatitis B vaccination series
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Medical transcription the free encyclopediaMedical transcription‚ also known as MT‚ is an allied health profession‚ which deals in the process of transcription‚ or converting voice-recorded reports as dictated by physicians or other healthcare professionals‚ into text format. History Evolution of transcription dates back to the 1960s. The method was designed to assist in the manufacturing process. The first transcription that was developed in this process was MRP‚ which is the acronym for Manufacturing
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OPERATIVE REPORT PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. OPERATION Left carpal tunnel decompression. ANESTHESIA IV regional. PROCEDURE FINDINGS The left transverse carpal ligament was moderately thickened‚ and it was causing moderate compression of the left median nerve in the carpal tunnel. DETAILS OF PROCEDURE The patient was brought conscious to the operating room and placed on the operating table in the supine
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Admitting Diagnosis: Ectopic pregnancy. Chief Complaint: Lower abdominal pain. HISTORY OF PRESENT ILLNESS: The patient states she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she states that she is sexually active and using no birth control. GYNECOLOGY HISTORY: Patient is gravida 2‚ para 1‚ abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother. PAST MEDICAL HISTORY: Positive
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known or spoken of in general is Medical Transcription. It is often confused with medical records and general dictation‚ but Medical Transcription is a specialty in a class of its own. Of all the medical branches that the general public has knowledge of‚ Medical Transcription shows as a big blank in most of our minds. Most MT departments are located within the Health Information Management section of a hospital or clinic‚ but some are located outside of medical facilities and are a business that
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OPERATIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/5 Age: 46 Sex: M Date of Admission: 11/15 Date of Procedure: 11/15 Admitting Physician: Bernard Caster‚ MD Surgeon: Bernard Caster‚ MD Assistant: Jason Wagner‚ PAC Circulating Nurse: Jimmy Dale Jet‚ RN Preoperative Diagnosis: Acute Appendicitis Postoperative Diagnosis: Perforated Appendicitis Operative Procedure: Laparoscopic Appendectomy Placement of right lower quadrant drain Anesthesia:
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OPERATIVE REPORT Hospital No.: 11259 Date of Surgery: 09-26-2014 Admitting Physician: Sherman Loyd‚ MD Surgeon: Carol Dodd‚ MD Preoperative Diagnosis: Right intertrochanteric femoral fracture. Postoperative Diagnosis: Right intertrochanteric femoral fracture. Operative Procedure: Open reduction internal fixation of right intertrochanteric femoral fracture with DePuy sliding screw. Anesthesia: General endotracheal. Indications: The patient is a 69-year-old
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OPERATIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/65 AGE:46 SEX: M Date of Admission: 11/14/2012 Date of Procedure: 11/14/2012 Admitting Physician: Bernard Kester‚ MD Surgeon: Bernard Kester‚ MD Assistant: Jason Wagner‚ PAC Circulating Nurse: Jimmy Dale Jett‚ RN Preoperative Diagnosis: Acute Appendicitis Postoperative Diagnosis: Perforated Appendicitis
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OPERATIVE REPORT Patient Name: Gerald Edwards Hospital No.: 11058 Date of Surgery: 07/17/2010 Admitting Physician: Catherine Baker‚ MD Surgeon: Gary Sheldon‚ DPM Date: 07/17/2010 Preoperative Diagnosis: Diabetic plantar space abscess of the right foot‚ and grade 2 diabetic ulceration of the right foot. Postoperative Diagnosis: Diabetic plantar space abscess of the right foot‚ and grade 2 diabetic ulceration of the right foot. Operative Procedure: Complicated incision and drainage of the
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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
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