First of all I am confused about the directions on pg. 71. ......the headings for this transcription, which are "BRIEF HISTORY" and 'PAST MEDICAL HISTORY', but the dictator dictates more such as problem list, medications etc. How do I treat those?
PROBLEM LIST
1. Anxieties.???????
Third paragraph under BRIEF HISTORY 1ST sentence
CT scan in the emergency room revealed a large amount of _____________.
1st sentence under PAST MEDICAL HISTORY
Patient was status post _________________ stroke which left him with gait
Totally lost under PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
_________________ frail appearing elderly man. Vital signs: Pulse 70 regular, blood pressure 140/82, temperature 96.7. Skin no ______________. HENT: No _______, neck without _____________, no carotid bruits. Lungs were clear. Heart systolic _________. Abdomen distended. Positive fluid _________. No masses. ___________ was negative.
CHEMISTRY
creatinine 1.1, _________ 2.5.
PLAN
The patient was discharged to Hospice home care on ______________ medical regimen.
THANK YOU, Karen