Cardiac a. Patient has chest pains if she lies on her left side for over a year. Correct:
Patient experiences episodes of angina or chest pain that occurs upon side lying on the left that persists for over a year now.
b. By the time he was admitted, his rapid heart had stopped, and he was feeling better. Correct:
The palpitation experienced by the patient subsides upon admission and now feels better with a normal heart rate.
c. Skin: somewhat pale, but present. Correct: Patient with a pale skin (pallor) but with normal skin integrity.
Musculoskeletal a. On the second day, the knee was better, and on the third day, it had completely disappeared. Correct: The patient’s knee condition gradually improved on the second day and the discomforts completely disappeared on the third day.b. While in the emergency department, she was examined, X-rated, and sent home. Correct: Patient was admitted to the emergency department, evaluated, examined and went through an x-ray test and was then discharged.
c. She slipped on ice and her legs went in separate directions in early December. Correct: In early December, the patient slipped on the ice and her legs got broken or fractured.
Neurologic a. Patient was alert but unresponsive. Correct: Patient is awake but unresponsive.
b. Healthy appearing, decrepit 69-year-old female, mentally alert, but forgetful. Correct: A 69 year old, healthy female patient who appears to be responsive but senile and forgetful.
c. When she fainted, her eyes rolled around the room. Correct: Patient fainted with the eyes rolling.
Gastrointestinal a. The patient had waffles for breakfast and anorexia for lunch. Correct: The patient is anorexic and only have waffles for breakfast and skips lunch.
b. Bleeding started in the rectal area and continued all the way to Los Angeles. Correct: Patient experienced bleeding in the rectal area that continues to persist throughout their travel time to Los Angeles.
c. Rectal examination revealed a normal-sized thyroid. Correct: The rectal examination revealed a regular size hemorrhoid.
Gynecologic/urologic a. Examination of genitalia reveals that he is circus-sized. Correct: Genital examination revealed that the patient is circumcised.
b. Indwelling urinary catheter draining large amounts of urine the color of American beer. Correct: The indwelling urinary catheter drains hazy colored urine.
c. Since she can""?t get pregnant without her husband, I thought you would like to work her up. Correct: The patient may need some work up upon experiencing some infertility issues.
Psychosocial a. The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week. Correct: Patient lives with his parents and is sent on a day care schooling three times a week.
b. The patient has two teenage children but no other abnormalities. Correct: The patient has two normal, healthy teenage children.
c. Examination reveals a well-developed male lying in be with his family in no distress. Correct:
The evaluation reveals that the male patient lives in a peaceful home with his family.
