This is out of the textbook, medical transcription seventh edition

DIRECTIONS: Using the instructions given for the 11-3 Review Test, type the following information into the patients' charts that you previously prepared. Use a date four days from the date you used for Review Test 11-3.

 

Remember that in actual practice you no longer have these records, and so you would make your transcripts one right after another, and they would be cut and pasted to the original. You can use cellophane tape to tape your entry to the appropriate document to reenact this procedure.

1. Gustavo deVargas. Patient telephoned office today and agreed to laparotomy. He is to be admitted to Valley Presbyterian Hospital tomorrow afternoon at 3 for surgery the following day.

2. Secretary: Please make your own entry into the chart showing that Mr deVargas was admitted to the hospital on the appropriate day.

3. Robin Vincenti. Chest clear to P\&A. X-ray is clear and shows normal heart silhouette. Full use of left hand; no residual pain or weakness. Plans to return to work tomorrow.

4. Mrs Esther Conway. Intravenous pyelogram and cystoscopy revealed multiple fistulae of bladder with two openings into urinary bladder and copious leakage into vagina. Continued to work. Diagnosis: multiple vesicovaginal fistulae. To be admitted to the hospital for repair.

5. Secretary: Please make your own entry into the chart for day of admission, four days from her last visit, into University Hospital for Mrs Conway.

DIRECTIONS: Retype the following data into an industrial accident report form and prepare an envelope. Use letterhead stationery. Use full block format, mixed punctuation, (see Chapter 6) and the current date. Watch for proper paragraphing, placement, punctuation, and mechanics.

 

The letter concerns the patient George R. Champion and was dictated by Dr James C. Taylor of 4532 Saint Charles Avenue, New Orleans, LA 70118. It is to be sent to an attorney, Ralph J. Claborne of 165 Colette, Suite A-1, New Orleans, LA 70120. Use a current date.

 

Dear Mr Claborne. My patient Mr George R. Champion was seen on September 14, 20XX. History of injury: Mr Champion was hit on the back of the head by a lettuce crate in April of 20XX. He saw stars but was not knocked unconscious. Present complaints: The patient says he can see for an instant then the left eye blurs and also itches. He has had this problem since his accident in April 20XX. When he is working and turns to the left he cannot see things out of that side since they are fuzzy. He can look at an object to the left and five seconds later it is gone. Physical examination: Visual acuity uncorrected: right eye, 20/80; left eye, 20/40. Manifest refraction: right eye, +1.75D = 20/30 Jaeger 1 ; left eye, +2.50 = 20/30 Jaeger 1 . Visual field: full centrally. Motility: Near point of convergence = 8 cm; Near point of accommodation =3.5 D. Prism cover test: Distance = no shift; Near =8 prism diopters exophoria. Cycloplegic refraction: right eye = +2.50 +0.50 x 30 = 20/25 - 2; left eye =+3.25 +0.75 x 125 = 20/20-1. Slit-lamp examination revealed abnormal cornea, conjunctiva, iris and lens. Ocular tension was 11 mmHg both eyes by applanation. Retinal examination revealed a normal optic disc, macula, vessels and periphery with direct and indirect ophthalmoscopy. Diagnosis: Compound hyperopic astigmatism with early presbyopia. Comments: I feel that this patient's focusing reserve was suddenly decreased by his accident when he was hit on the head. His basic problem of farsightedness coupled with a general weakness after the accident overcame his focusing reserve and caused his symptoms. I feel that glasses of the proper strength will enable him to see and focus. His problem of poor convergence and exophoria at near were also brought into prominence by the weakness he had after the accident. His age (38) means that he would have had symptoms within the next five or seven years due to his farsightedness. Recommended treatment: Glasses to be worn all the time. Eye exercises for convergence problem if the glasses do not relieve his symptoms. Disability: The condition is now stationary and permanent; and with the proper glasses, he should be able to resume his normal work load. Very truly yours.