7-web-cryptophiles answers

DISCHARGE DIAGNOSES: 1. Right upper lobe pneumonia. 2. Right hilar lymph node borderline size at 1.5 cm. 3. Obesity. 4. Hypertension. 5. History of hypothyroidism. 6. Gastroesophageal reflux disease. 7. History of dyslipidemia, died1 controlled. 8. Allergic rhinitis. CONSULTANTS: Pulmonology HOSPITAL COURSE: This is a 66-year-old female who presented to the emergency department with subjective fevers. She also had associated chills. She had been having a dry cough with worsening shortness of breath and dyspnea on exertion. X-ray revealed a questionably2 right perihilar mass. A CAT scan of the thorax revealed an infiltrate in the right upper lobe as well as 1.5 cm right hilar lymph node. Patient was started on intravenous Avelox for her pneumonia. She was evaluated by pulmonology. Bronchoscopy was performed which revealed mucopurulence and thick exudate in the left main stem bronchus. There was also purulent exudate in the right main stem bronchus, in the right middle and lower lobes. There was no endobronchial gross3 present. Culture from bronchoscopy so for an4 unremarkable. The patient's condition improved during the course of her stay. She has been cleared by pulmonology to be discharged home. DISCHARGE INSTRUCTIONS: Patient instructed to take her medication as prescribed. She is instructed to follow up with pulmonology in 2 weeks' time. Cholesterol5 her primary care for an appointment in 2 to 4 weeks' time. Patient will have a CAT scan and/or PET scan as an outpatient for further workup regarding the enlarged lymph node. ANSWER KEY: 1) Spelling error, SR or draft error? Diet 2) Spelling or draft error? Questionable 3) Draft error not corrected. Growth 4) Draft error not corrected, “extra sound”. Delete an 5) Apparent expander error (when making draft edit?) Call CORRECTED REPORT: DISCHARGE DIAGNOSES: 1. Right upper lobe pneumonia. 2. Right hilar lymph node borderline size at 1.5 cm. 3. Obesity. 4. Hypertension. 5. History of hypothyroidism. 6. Gastroesophageal reflux disease. 7. History of dyslipidemia, diet controlled. 8. Allergic rhinitis. CONSULTANTS: Pulmonology HOSPITAL COURSE: This is a 66-year-old female who presented to the emergency department with subjective fevers. She also had associated chills. She had been having a dry cough with worsening shortness of breath and dyspnea on exertion. X-ray revealed a questionable right perihilar mass. A CAT scan of the thorax revealed an infiltrate in the right upper lobe as well as 1.5 cm right hilar lymph node. Patient was started on intravenous Avelox for her pneumonia. She was evaluated by pulmonology. Bronchoscopy was performed which revealed mucopurulence and thick exudate in the left main stem bronchus. There was also purulent exudate in the right main stem bronchus, in the right middle and lower lobes. There was no endobronchial growth present. Culture from bronchoscopy so for unremarkable. The patient's condition improved during the course of her stay. She has been cleared by pulmonology to be discharged home. DISCHARGE INSTRUCTIONS: Patient instructed to take her medication as prescribed. She is instructed to follow up with pulmonology in 2 weeks' time. Call her primary care for an appointment in 2 to 4 weeks' time. Patient will have a CAT scan and/or PET scan as an outpatient for further workup regarding the enlarged lymph node.

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