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1. Subject 57173 Job 188698 – Dr. Voogjarv - Report #2112-0049
OPERATION DATE:
DECEMBER 17, 2010
SURGEON:
DR. HARRY VOOGJARV
PREOPERATIVE DIAGNOSIS:
RIGHT LOWER QUADRANT PAIN
POSTOPERATIVE DIAGNOSIS:
LIKELY ADHESIONS AND IBS, NO EVIDENCE OF MUCOSAL ABNORMALITY
PROCEDURE:
1. COLONOSCOPY
2. ILEOSCOPY
ANESTHESIA:
ASSISTANT:
CLINICAL NOTE:
This 37-year-old woman has right-sided pain, sometimes near the right ASIS. Sometimes subcostal. She has
undergone laparoscopic cholecystectomy and problems date back towards then. No choledocholithiasis.
Abdomen is soft and benign. She is on no medications and has no drug allergies.
Of note the pain is worse when she lies on her right side down.
Abdomen is scaphoid. Weight is down a bit over the last year. There are no masses, tenderness or
organomegaly.
Colonoscopy is arranged.
PROCEDURE:
Following sedation by anesthesia, the videocolonoscope was introduced anally and passed retrograde following
insufflation with air. A bit more than average spasm. Good views. No diverticula or polyps or acute
inflammation. Cecum reached. Ileum intubated and run for 10-20 cm. All mucosa in the rectum, colon and
ileum looks normal.
I am going to try her on high fiber-low fat diet and if that does not improve things, she might possibly be
considered for laparoscopy as she may have postop adhesions.
This procedure was well tolerated.
No evidence of perforation.
Thank you for the referral.
SHOULD BE
OPERATION DATE:
DECEMBER 17, 2010
SURGEON:
DR. HARRY VOOGJARV
PREOPERATIVE DIAGNOSIS:
RIGHT LOWER QUADRANT PAIN
POSTOPERATIVE DIAGNOSIS:
LIKELY ADHESIONS AND IBS, NO EVIDENCE OF MUCOSAL ABNORMALITY
PROCEDURE:
1. COLONOSCOPY
2. ILEOSCOPY
ANESTHESIA:
ASSISTANT:
CLINICAL NOTE:
This 37-year-old woman has right-sided pain, sometimes near the right ASIS, sometimes subcostal. She has
undergone laparoscopic cholecystectomy and problems date back towards then. An MRI has shown no
choledocholithiasis.
Abdomen is soft and benign. She is on no medications and has no drug allergies.
Of note, the pain is worse when she lies on her right side down.
Abdomen is scaphoid. Weight is down a bit over the last year. There are no masses, tenderness, or
organomegaly.
Colonoscopy is arranged.
PROCEDURE:
Following sedation by Anesthesia, the video colonoscope was introduced anally and passed retrograde following
insufflation with air. A bit more than average spasm. Good views. No diverticula, (the extra “or” is not
necessary here) polyps, or acute inflammation. Cecum reached. Ileum intubated and run for 10-20 cm. All
mucosa in the rectum, colon, and ileum looks normal.
I am going to try her on high fiber-low fat diet and if that does not improve things, she might possibly be
considered for laparoscopy, as she may have postop adhesions.
This procedure was well tolerated.
No evidence of perforation.
Thank you for the referral.
Missing words – This is a critical error and in this case, it contains important information as well.
Space between two words
Commas
Capitalize departments.
2. Subject 89266 Job 187632 – Dr. Carette – Report #2112-0055
REFERRING PHYSICIAN:
Date of Clinic:
Dr. Alexis Goth
December 10, 2010
Dear Dr. Goth:
Thank you very much for referring Mrs. Lambert for assessment of her rheumatoid nodules.
She is a 50-year-old woman, moderately obese, who smokes half a pack of cigarettes a day and is asthmatic but
otherwise has no significant past medical or surgical history.
Her mother has psoriasis.
For the past year and a half to two years, she was found to have lumps along the extensor surface of her
forearms.
Two of these were biopsied and they each showed changes highly consistent with rheumatoid
nodules. She does have a positive rheumatoid factor but otherwise the rest of her serology is negative. I do not
think that she was tested for anti-CCP antibodies.
Interestingly she does not report any joint pain or morning stiffness.
She has no family history of rheumatoid arthritis.
On examination, she was an overweight woman whose joint examination is strictly normal. She did have fairly
large painless nodules in her olecranon bursa bilaterally as well as along the extensor surface of both her arms.
These extended all the way to at least her distal forearm.
She had a chest x-ray which was normal.
IMPRESSION:
I must admit that this is the first time that I see such impressive nodulosis in the absence of arthritis.
I am not aware of any agent that has been studied specifically for rheumatoid nodulosis. Typically we treat the
arthritis with various agents with the hope that controlling the arthritis would also have an effect on the nodules.
This being said, methotrexate as you may be aware, can sometimes cause a significant aggravation of
rheumatoid nodules even while the patient’s arthritis is actually improving. As Mrs. Lambert is not too bothered
by these nodules, I would recommend that we do not do anything. Surgical excision is an option but typically
they tend to recur. Therefore I would reserve this approach only if they were becoming very bothersome to her.
SHOULD BE
REFERRING PHYSICIAN:
Dr. Alexis Goth
Date of Clinic:
December 10, 2010
Dear Dr. Goth:
Thank you very much for referring Mrs. Lambert for assessment of her rheumatoid nodules.
She is a 50-year-old woman, moderately obese, who smokes half a pack of cigarettes a day, (“and is not
necessary here) is asthmatic, but otherwise has no significant past medical or surgical history. Her mother has
psoriasis.
For the past year and a half to two years, she was found to have lumps along the extensor surface of her
forearms.
Two of those were biopsied and they each showed changes highly consistent with rheumatoid
nodules. She does have a positive rheumatoid factor but otherwise the rest of her serology is negative. I do not
think that she was tested for anti-CCP antibodies.
Interestingly, she does not report any joint pain or morning stiffness.
She has no family history of rheumatoid arthritis.
On examination, she was an overweight woman whose joint examination was strictly normal. She did have fairly
large painless nodules in her olecranon bursa bilaterally, as well as along the extensor surface of both her arms.
These extended all the way to at least her distal forearm.
She had a chest x-ray, which was normal.
IMPRESSION:
I must admit that this is the first time that I see such impressive nodulosis in the absence of arthritis.
I am not aware of any agent that has been studied specifically for rheumatoid nodulosis. Typically we treat the
arthritis with various agents with the hope that controlling the arthritis would also have an effect on the nodules.
This being said, methotrexate, as you may be aware, can sometimes cause a significant aggravation of
rheumatoid nodules even while the patient’s arthritis is actually improving. As Mrs. Lambert is not too bothered
by these nodules, I would recommend that we do not do anything. Surgical excision is an option but typically
they tend to recur. Therefore, I would reserve this approach only if they were becoming very bothersome to her.
Commas
Verb tense (x2)
3. Subject 28210 Job 187673 Dr. Rubin – Report #2112-0063
REFERRING PHYSICIAN:
Date of Clinic:
Dr. Guy Lupien
December 10, 2010
DIAGNOSIS: Seronegative rheumatoid arthritis.
MEDICATIONS:
1. Arava 10 mg daily
2. Prednisone 5 mg daily
OTHER MEDICATIONS:
1. Metoprolol
2. Sinemet
3. Omeprazole
4. Lasix
5. Zoplicone
6. Premarin
Mrs. Bertrand was last seen in 2006 and has done generally quite well with respect to her inflammatory
arthritis.
Multidimensional Health Assessment Questionnaire today reveals functional score 0.7, pain 4.5, global
3, fatigue 3, status since the last visit 4, joint score 2.3, morning stiffness 30 minutes, ACR functional
class III. Calculated RAPID 3 score was 3.2.
She has also been receiving spinal injections for longstanding degenerative disc disease, sciatica and she
can arrange this with St. Michael’s interventional radiologist on her own.
Her replaced left shoulder has continued to do well followed by Dr. McGhee. She is not interested in
having the right shoulder addressed surgically.
The remainder of the functional inquiry is otherwise noncontributory. There are no significant active
comorbidities at the present time.
She tells me her blood pressure has been a bit of a problem and that is being monitored carefully and I
note she is on metoprolol. Height and weight are stable.
On examination, she had only one tender minimally swollen joint (right third PIP) with grip strength 240
on that side versus greater than 300 on the left. There is no active synovitis elsewhere, no significant
skin rash or lymphadenopathy and the chest is clear.
She is reluctant to reduce the prednisone and I concur. The dose of Arava is relatively low but can be
continued. Routine laboratory monitoring every three months is generally acceptable.
Recent
laboratory studies in October demonstrated normal chemistry and hematology, negative rheumatoid
factor, TSH minimally elevated at 6.69 with normal T4, total cholesterol 6.45 and normal liver function
tests. ANA reportedly negative.
No changes were made to her overall regimen and no follow ups was deemed necessary at this time but
we would be happy to see her in clinic again at your request.
Thank you for allowing me to take part in her care.
Sincerely,
SHOULD BE
REFERRING PHYSICIAN:
Date of Clinic:
Dr. Guy Lupien
December 10, 2010
DIAGNOSIS: Seronegative rheumatoid arthritis.
MEDICATIONS:
3. Arava 10 mg daily
4. Prednisone 5 mg daily
OTHER MEDICATIONS:
7. Metoprolol
8. Sinemet
9. Omeprazole
10. Lasix
11. Zoplicone
12. Premarin
Mrs. Bertrand was last seen in 2006 and has done generally quite well with respect to her inflammatory
arthritis.
Multidimensional Health Assessment Questionnaire today reveals functional score 0.7, pain 4.5, global
3, fatigue 3, status since the last visit 4, joint score 2.3, morning stiffness 30 minutes, ACR Functional
Class III. Calculated RAPID 3 score was 3.2.
She has also been receiving spinal injections for longstanding degenerative disc disease and sciatica. She
can arrange this with St. Michael’s interventional radiologist on her own.
(This is grammatically
better)
Her replaced left shoulder has continued to do well followed by Dr. McGhee. She is not interested in
having the right shoulder addressed surgically.
The remainder of the functional inquiry is otherwise noncontributory. There are no significant active
comorbidities at the present time.
She tells me her blood pressure has been a bit of a problem and that is being monitored carefully. (the
“and” was not dictated) I note she is on metoprolol. Height and weight are stable.
On examination, she had only one tender minimally swollen joint (right third PIP) with grip strength 240
on that side versus greater than 300 on the left. There is no active synovitis elsewhere, no significant
skin rash or lymphadenopathy, and the chest is clear.
She is reluctant to reduce the prednisone and I concur. The dose of Arava is relatively low but can be
continued. Routine laboratory monitoring every three months is generally acceptable.
Recent
laboratory studies in October demonstrated normal chemistry and hematology, negative rheumatoid
factor, TSH minimally elevated at 6.69 with normal T4, total cholesterol 6.45, and normal liver function
tests. ANA reportedly negative.
No changes were made to her overall regimen and no followup (noun form) was deemed necessary at
this time but we would be happy to see her in clinic again at your request.
Thank you for allowing me to take part in her care.
Sincerely,
Just a bit of grammar here, otherwise perfect.
4. Subject 47129 Job 188195 – Dr. Rabinovich – Report #2112-0237
REFERRING PHYSICIAN:
Date of Visit:
ORTHOPEDIC CLINIC:
Chief Complaint:
Left arm foreign body.
November 29, 2010
This is a 23-year-old gentleman who was working and had a work-related injury at which point a piece
of metal went into his left arm in the biceps area on November 25, 2010.
He went to the Emergency Department, had the wound cleaned, and was given antibiotics.
He has been doing well since the injury. The wound in the biceps actually appears to be healing quite
well and overall he is actually not feeling too much discomfort.
No signs or symptoms of infection. No fever, chills or sweats.
On examination, alert and oriented x 3, afebrile, vital signs stable.
The left arm was examined. The little foreign body cannot be palpated by myself and I could not elicit
any painful area on his biceps area.
X-ray evaluation of the left arm shows a small metallic foreign body which measures less than a cm. It
appears to be on the medial aspect of his biceps. It appears to be superficial however I cannot palpate it
myself.
IMPRESSION AND PLAN:
This 23-year-old gentleman with a left arm foreign body in the biceps.
At this time, I am recommending nonoperative treatment. It is causing him minimal discomfort and
there appears to be no signs of infection.
I have recommended that he try to work around this issue and I will see him back in a month or two
depending on his symptoms.
If he has no symptoms and he is back to regular activities, then the foreign body can stay there without
any complications. However if it gives him any problems, I am more than happy to see him again and
potentially take it out.
I have told him that this is a complex situation because it is like searing for a needle in a haystack and on
the medial aspect of the left arm it is near the neurovascular bundle which may be difficult exploration.
The patient understands this and does not want surgery at this time and will come back to me in a couple
of months if there are any issues.
SHOULD BE
REFERRING PHYSICIAN:
Date of Visit:
November 29, 2010
ORTHOPEDIC CLINIC:
Chief Complaint:
Left arm foreign body.
This is a 23-year-old gentleman who was working and had a work-related injury at which point a piece
of metal went into his left arm in the biceps area on November 25, 2010.
He went to the Emergency Department, had the wound cleaned, and was given antibiotics.
He has been doing well since the injury. The wound in the biceps actually appears to be healing quite
well and overall he is actually not feeling too much discomfort.
No signs or symptoms of infection. No fever, chills, or sweats.
On examination, alert and oriented x 3, afebrile, vital signs stable.
The left arm was examined. The little foreign body cannot be palpated by myself and I could not elicit
any painful area on his biceps area.
X-ray evaluation of the left arm shows a small metallic foreign body, which measures less than a
centimeter. (when not mentioning a specific measurement like 2 cm, it should be written out) It appears
to be on the medial aspect of his biceps. It appears to be superficial; however, I cannot palpate it myself.
(or it could be written as “…superficial. However, I…”)
IMPRESSION AND PLAN:
This is a ( he does not dictate this but it is grammatically correct) 23-year-old gentleman with a left arm
foreign body in the biceps.
At this time, I am recommending nonoperative treatment. It is causing him minimal discomfort and
there appears to be no signs of infection. (should be either “appear to be no signs” or “appears to be no
sign” to be grammatically correct)
I have recommended that he try to work around this issue and I will see him back in a month or two
depending on his symptoms.
If he has no symptoms and he is back to regular activities, then the foreign body can stay there without
any complications. However, if it gives him any problems, I am more than happy to see him again and
potentially take it out.
I have told him that this is a complex situation because it is like searching (missing letters so wrong
word) for a needle in a haystack and on the medial aspect of the left arm, it is near the neurovascular
bundle, which may be difficult exploration.
The patient understands this, does not want surgery at this time, and will come back to me in a couple of
months if there are any issues.
Just some grammar in this report, otherwise nice job.
4. Subject 35978 Job 189130 – Dr. Munnoch – Report #2112-0211
OPERATION DATE:
DECEMBER 20, 2010
SURGEON:
DR. KATHERINE MUNNOCH
PREOPERATIVE DIAGNOSIS:
POST MENOPAUSAL BLEEDING
POSTOPERATIVE DIAGNOSIS:
PROCEDURE:
ANESTHESIA:
FINDINGS:
1. HYSTEROSCOPY
2. D&C
GENERAL BY DR. ANDREW
TOUW, LOCUM ANESTHETIST
ASSISTANT:
1. Normal atrophic cavity.
2. No polyps or fibroid noted.
PROCEDURE NOTE:
The patient was taken to the Operating Room where a general anesthetic was placed without
complication. She was placed in the lithotomy position with legs in Candy Cane stirrups. She was
prepped and draped in a sterile fashion. She was examined under anesthesia and was found to have a
bulky anteverted uterus with moderately good descent, no adnexal masses.
A Sims speculum was placed in the vagina and the anterior lip of the cervix grasped with a single tooth
tenaculum. Her cervix was dilated to a number 8 Hegar dilation. The hysteroscope was advanced with
saline running. The cavity was small, atrophic in appearance, though on both sides it looked as though
there might have been a small amount of thicker tissue on either side, but no distinct polyps or fibroids
noted. The hysteroscope was removed. A sharp curettage was carried out giving careful attention to
both of those side walls but there was no tissue to be removed. This was consistent with a atrophic
endometrial lining however there was a scant scraping that was sent for pathology. All instruments were
removed. The patient tolerated the procedure well and was taken to the Recovery Room in stable
condition. Sponge count was correct at the end of the procedure.
Estimated blood loss: negligible.
SHOULD BE
OPERATION DATE:
DECEMBER 20, 2010
SURGEON:
DR. KATHERINE MUNNOCH
PREOPERATIVE DIAGNOSIS:
POST MENOPAUSAL BLEEDING
POSTOPERATIVE DIAGNOSIS:
PROCEDURE:
ANESTHESIA:
1. HYSTEROSCOPY
2. D&C
GENERAL BY DR. ANDREW
TOUW, LOCUM ANESTHETIST
ASSISTANT:
FINDINGS: (Findings can also go under postop diagnoses, but this is not incorrect)
1. Normal atrophic cavity.
2. No polyps or fibroids noted.
PROCEDURE NOTE:
The patient was taken to the Operating Room where a general anesthetic was placed without
complication. She was placed in the lithotomy position with legs in Candy Cane stirrups. She was
prepped and draped in a sterile fashion. She was examined under anesthesia and was found to have a
bulky anteverted uterus with moderately good descent, no adnexal masses.
A Sims speculum was placed in the vagina and the anterior lip of the cervix grasped with a single tooth
tenaculum. Her cervix was dilated to a number 8 Hegar dilation. The hysteroscope was advanced with
saline running. The cavity was small, atrophic in appearance, though on both sides it looked as though
there might have been a small amount of thicker tissue on either side, but no distinct polyps or fibroids
noted. The hysteroscope was removed. A sharp curettage was carried out, giving careful attention to
both of those sidewalls (one word) but there was no tissue to be removed. This was consistent with an
(grammatically correct) atrophic endometrial lining. However, (here she actually dictates the period
before “however”) there was a scant scraping that was sent for pathology. All instruments were
removed. The patient tolerated the procedure well and was taken to the Recovery Room in stable
condition. Sponge count was correct at the end of the procedure.
Estimated blood loss: negligible.
Nice job, just some grammar.
5. Subject 16968 Job 188680 – Dr. Mano Raveendran – Report #2112-0083
ADMISSION DIAGNOSIS:
DISCHARGE DIAGNOSIS:
1. DEPRESSION
2. SUBSTANCE ABUSE DISORDER
MOST RESPONSIBLE DIAGNOSIS (MR DX):
ONE DIAGNOSIS ONLY
PRIMARY DIAGNOSIS:
(TYPE 1)
PRE-ADMIT COMORBIDITY
COMPLICATIONS:
POST-ADMIT
COMORBIDITY
SECONDARY DIAGNOSIS:
(TYPE 2)
(TYPE 3)
CHRONIC CONDITIONS
PRINCIPAL PROCEDURE:
OTHER PROCEDURES:
CONSULTANTS:
Mrs. Payette is a 74-year-old lady who was admitted on a Form 1. On admission, she stated she cannot
stay with her husband. She stated she took an overdose because she wanted to get out of Gogama. She
stated she felt lonely in the wintertime having experienced some crying spells, feeling increasingly
depressed. She stated she was sleeping well. It turned out that she has been taking some of her
husband’s medications as well. Appetite is poor. She has lost about 25 pounds. She stated that on the
day of admission she came to Timmins to do groceries with her husband and went back home and she
stated she started drinking and then took a couple of pills and then also took some of her husband’s pills.
She wanted to sleep. She felt shaky, got scared of dying and then called her husband. From downstairs,
he came up and called the ambulance. The patient admits that she drinks about 2-4 beer every day. She
stated that her main stressor is that she wants to be out of Gogama.
PAST HISTORY:
This lady was diagnosed last year around this time with depression. Many years ago, she was diagnosed
with bipolar mood disorder. There was no past history of intentional overdose or mania. She has five
children, three of them live out west. Four of the five children have drugs and alcohol problems. She
lives with her husband who also drinks quite heavily.
PAST MEDICAL HISTORY:
She suffers from hypertension and hypothyroidism.
FAMILY HISTORY:
One of her sisters was diagnosed with some psychiatric illness and spent some time in the psychiatric
hospital.
The first few days, Mildred was quite emotional, irritable with the staff. Her mood was up and down.
Later she admitted that she was taking her husband’s Ativan and Diazepam along with her medications.
It was evident that she was going through withdrawal. She also said that she took some of his pain pills
as well. She was started on Ativan 1 mg sublingually and her regular medications. She did experience
restlessness at night time so we started her on clonazepam 0.25 mg at bedtime. With that she became
very settled. Her mood was much better. Because her blood pressure was high, ramipril was increased
to 2.5 mg twice a day. Since she has done well, she was discharged today. She did have a lesion on her
hand. Dr. Vaithilingam has done a biopsy and removed the whole thing as well yesterday.
MEDICATIONS ON DISCHARGE:
1. Soluble aspirin 81 mg once a day
2. Metoprolol 50 mg twice a day
3. Synthroid 75 micrograms once a day
4. Ramipril 2.5 mg twice a day
5. Nifedipine 60 mg once daily
6. Seroquel 50 mg at bedtime
7. Remeron 30 mg at bedtime
She was advised to continue follow up with her family doctor.
SHOULD BE
ADMISSION DIAGNOSIS:
DISCHARGE DIAGNOSIS:
1. DEPRESSION
2. SUBSTANCE ABUSE DISORDER
MOST RESPONSIBLE DIAGNOSIS (MR DX):
ONE DIAGNOSIS ONLY
PRIMARY DIAGNOSIS:
(TYPE 1)
PRE-ADMIT COMORBIDITY
COMPLICATIONS:
POST-ADMIT
COMORBIDITY
SECONDARY DIAGNOSIS:
(TYPE 2)
(TYPE 3)
CHRONIC CONDITIONS
PRINCIPAL PROCEDURE:
OTHER PROCEDURES:
CONSULTANTS:
Mildred (she dictates the patient’s first name) is a 74-year-old lady who was admitted on a Form 1. On
admission, she stated she cannot stay with her husband. She stated she took an overdose because she
wanted to get out of Gogama. She stated she felt lonely in the wintertime, having experienced some
crying spells, feeling increasingly depressed. She stated she was sleeping well. It turned out that she
has been taking some of her husband’s medications as well. Appetite is poor. She has lost about 25
pounds.
She stated that on the day of admission, she came to Timmins to do groceries with her
husband and went back home. (divide this up to prevent a run-on sentence) She stated she started
drinking, (again take out this “and” to prevent a run-on sentence) then took a couple of pills, and then
also took some of her husband’s pills. She wanted to sleep. She felt shaky, got scared of dying, and then
called her husband. From downstairs, he came up and called the ambulance. The patient admits that she
drinks about 2-4 beers every day. She stated that her main stressor is that she wants to be out of
Gogama.
PAST HISTORY:
This lady was diagnosed last year around this time with depression. Many years ago, she was diagnosed
with bipolar mood disorder. There was no past history of intentional overdose or mania. She has five
children, three of them live out west. Four of the five children have drugs and alcohol problems. She
lives with her husband who also drinks quite heavily.
PAST MEDICAL HISTORY:
Mildred (again, she dictates the patient’s first name) suffers from hypertension and hypothyroidism.
FAMILY HISTORY:
One of her sisters was diagnosed with some psychiatric illness and spent some time in the psychiatric
hospital.
The first few days, Mildred was quite emotional, irritable with the staff. Her mood was up and down.
Later she admitted that she was taking her husband’s Ativan and Diazepam, along with her medications.
It was evident that she was going through withdrawal. She also said that she took some of his pain pills
as well. She was started on Ativan 1 mg sublingually and her regular medications. She did experience
restlessness at nighttime, so we started her on clonazepam 0.25 mg at bedtime. With that, she became
very settled. Her mood was much better. Because her blood pressure was high, ramipril was increased
to 2.5 mg twice a day. Since she has done well, she was discharged today. She did have a lesion on her
hand. Dr. Vaithilingam has done a biopsy and removed the whole thing as well yesterday.
MEDICATIONS ON DISCHARGE:
1. Soluble aspirin 81 mg once a day
2. Metoprolol 50 mg twice a day
3. Synthroid 75 mcg (the short form should be used here to be consistent with the other drug dosage
abbreviations) once a day
4. Ramipril 2.5 mg twice a day
5. Nifedipine 60 mg once daily
6. Seroquel 50 mg at bedtime
7. Remeron 30 mg at bedtime
She was advised to continue followup with her family doctor.
Follow up – verb form
Followup – noun form
Good job, just some grammar.