RADIOLOGY REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M CT Scan No: 10-790031 Ordering Physician: Alex McClure‚ MD Procedure: CT scan of abdomen and pelvis without contrast. Date of Procedure: 11/14/2012 HISTORY: RLQ pain‚ no previous studies. ABDOMEN: The lung basis appeared unremarkable. The liver‚ spleen‚ gallbladder‚ adrenals‚ kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened
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axially artery treated last year at Hillcrest. He had an embolectomy and has been on Coumadin since. INR is significantly elevated at 16. None the less‚ because of the cavitary lesions that are seen in the right and left upper lobes‚ the possibility of tuberculosis has been raised. Ancillary history was been given by the wife‚ Nupaul‚ with the patient translating for her from the Indie language. PAST HISTORY: Tuberculosis is the past. Embolectomy at Hillcrest last year. SOCIAL HISTORY: Married
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RESEARCH PROJECT Background As a medical transcriptionist‚ you’ll work with many different medical specialties. It’s important to have a basic knowledge of medical specialties so you can better understand the medical transcription submitted. Procedure Go to http://lessons.pennfoster.com/pdf/sp0754.pdf to read the instructions for research projects. Then follow these steps: 1. Identify eight medical specialties. List the specialties and write two paragraphs about seven specialities. 2
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A medical transcriptionist works with many different medical specialties. Each specialty is unique‚ yet each needs assistance from health care workers in other specialties to do their jobs. Eight medical specialties that will be reviewed are: radiology‚ dermatology‚ cardiology‚ obstetrics and gynecology‚ psychiatry‚ neurology‚ ophthalmology‚ and orthopedics. The eighth specialty‚ orthopedics‚ will be reviewed in the most detail. RADIOLOGY The main purpose of one field of medicine is to assist
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upper and lower extremities‚ although occasionally on her left‚ that is becoming more frequent although still is intermittent. ALLERGIES No known drug allergies. MEDICATIONS She is on multivitamin daily and Premarin 0.625 mg daily. PAST MEDICAL HISTORY She had the back problems as above. Has migraine headaches since about 10. Has had about 4 in the last 2 years‚ not very frequent. She has a history of asthma. No other chronic problems. PAST SURGICAL HISTORY She had tonsillectomy‚ hysterectomy
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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Lydia Cruz Patient ID: DOB: Age: 40 Sex: F Hospital Number: 11723 Room No.: 425 Date of Admission/Date of Arrival: 05/26/2012 Admitting/Attending Physician: Tomas Burgos‚ MD Admitting Diagnosis: Questionable Herniated disk. Chief Complaint: Low back pain‚ right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old black Latin female presents with complaints of low back and right
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to worsening redness as well as infection of the nail bed. Orthopedics consult was requested on 09/30/---- for possible paronychia. The patient at that time was having no fevers or chills and he was tolerating his antibiotic regiment well. PAST MEDICAL SURGICAL HISTORY: None other than circumcision shortly after birth. BIRTH HISTORY: Normal full-term vaginal delivery. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: Patient lives with his mother and a sibling‚ Father deceased. PHYSICAL
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past. D: She had left foot surgery in the remote past at Hillcrest by Dr. Smith‚ myself. E: She had right hip surgery 28 years ago. F: She had left hip surgery 26 years ago. G: 17 years ago she had a stage 2 left hip procedure completed 15 years ago. H: She had left hip revision 12 years ago. I: Nine years ago she had a mass on the bottom of her foot removed by Dr. Shelton of Podiatry . SOCIAL HISTORY: She works in the medical field. Enjoys a healthy social life‚ lives alone‚ is single
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OPERATIVE REPORT Patient Name: Putul Barua Patient ID: 135799 Room: CCU4 Date of Surgery: 01/08/2013 Admitting Physician: Dr. Simon Williams‚ MD Pulmonology Surgeon: Dr. Simon Williams‚ MD Pulmonology Preoperative Diagnosis: Recent onset hemoptysis‚ history of tuberculosis. Postoperative Diagnosis: No tuberculosis lesions seen. Operative Procedure: Bronchoscopy. Specimens Removed: Blood clots. Indications: Patient requires bronchoscopy because of recent onset hemoptysis and a
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TRANSCRIPTION Submitted To: Ma’am Shumaila Nadeem Submitted By: Zinnia Shah Date of Submission: Sep’25th-2014 KINNAIRD COLLEGE for WOMEN CONTENTS Introduction to transcription in eukaryotic cells -RNA-polymerases -promoters -outline of steps involved in transcription -transcription factors -basal-transcription-apparatus
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