Medical Transcription

At today's visit he is awake, alert and oriented. He complains of generalized pain. He states “I have pain all over today, my head, my back, my feet" I have not felt good for the last few days”. He rates his pain as 6/10 in severity; he describes his pain as shooting pain in different places. His pain does

2. Patient is experiencing acute pain r/t coughing and deep breathing aeb wheezing in the right and left upper lobes of the lungs.

The rest of patient report symptoms either related to small or large vessel thrombosis or both

Risk for infection related to surgical wound on her left upper back and drainage tube in left lung. I chose this as the second nursing diagnosis and would also rate this high priority. The patient did not have a

I recommend he follow up with his primary doc when he is released. Gave him Naprosyn 375 b.i.d. for his tooth pain. Discussed reflux precautions. Follow-up here

DESCRIPTION OF PROCEDURE: Patient was taken to the operating room and placed in the supine position. After satisfactory general endotracheal anesthesia was administered, the (nose) was packed with (pledgets) soaked in 4% (cocaine). The (pledgets) were removed and then the (middle turbinates) and the region of the lateral nasal wall were injected with 2% Xylocaine with 1:100,000 epinephrine. The nose was then repacked with the (cocaine pledgets). (___) (___) McIvor mouth retractor was placed. The opening to (Stensen's duct) was identified in the left buccal mucosa and (a biopsy) using a 4mm punch was taken from the

07/30/14 PT Notes showed that the patient had no new complaints. The patient is progressing well. It was noted to continue with a reassessment on next visit.

PHYSICAL EXAM: The leg itself looks good with minimal to no swelling. He has absolutely no calf pain to palpation and no pretibial edema. The ankle is just a little bit stiff. Dorsiflexion is to about zero. Plantar flexion is better. All wounds are healed at this point.

Elijah “Poochie” Diaz 8/27/15 mouth mirror inspection; TEMP 101.4°F; PUL 78; RESP 14; BP 110/75; HHUD patient has tenderness in his neck; while preforming extra oral exam noticed swelling and warmth on the submandibular nodes; soft tissue hard tissue NSF_______dira4620

Tympanic membranes: Right and left were completely clear. Saw no swelling, no fluid, no redness, no discharge.

The patient had no evident comorbidities. An IV antibiotic regimen was begun and after 5 days,

The patients tongue is slightly pale, slightly dusky, scalloped on the side, and the tongue has a thin white coat. The patient’s vital signs were a heart rate seventy-two, and his blood pressure was one hundred-ten over seventy. No orthopedic

Try to stop the bleeding by applying pressure to the wound with a clean, dry cloth.

describes the pain as shooting. He reports as located this a non-heart failure eminences bilaterally

checking to make sure the airway is opened and treating it if needed. Some signs of a