Posted by Kim on Friday, August 26, 2011 at 8:04pm.
Is this properly punctuated?
She was admitted for chest pain. The patient was admitted on ___ [DATE], having woke up with discomfort, heavy substernal area and pressure radiating into midscapular areas. Notably, she also felt dizzy this morning and felt a little bit short of breath with this. Slowly the chest pain got worse over time, up to a 8 out of 10, currently at admission it was down slightly. No fevers or chills. Recent radiation therapy, wedge resection of the upper lung and also a mediastinal incision. That area is still tender.
PAST MEDICAL HISTORY
1. Breast cancer stage II, chemotherapy treatment for that.
2.Lung cancer stage III.
5. Multinodular goiter.
6. Bilateral mastectomy ___ [DATE].
7. Total abdominal hysterectomy/BSO.
8. Mediastinoscopy and left thoracotomy.
9. Mediastinal biopsy and wedge resection of her left upper lobe ___ [DATE].
DRUG ALLERGIES: CODEINE, LEADING TO NAUSEA.
HOSPITAL COURSE: She was admitted, her (___) were negative, she did have a little bit of tachycardia. Stress echocardiogram was performed and that was negative. D-dimer was negative. Chest x-ray, no obvious infiltrates, obviously some post surgical changes. Noted apparent EKG, no change in her nonspecific EKG changes. Her chronic obstructive pulmonary disease remains stable. She was given some IV fluid for her tachycardia and her light headiness resolved with that also.
1. Noncardiac chest pain, likely esophageal and or chest wall, secondary to her surgery and radiation therapy.
2. Prilosec added. However, I think she will have ongoing symptoms.
3. She does have underlying anxiety and that played a component into her not tolerating her symptoms well, continue her routine Ativan.
4. Dehydration, I recommend she be sure she takes enough fluid with enough salt, and take to stay well hydrated.
5. Chronic obstructive pulmonary disease, stable.
6. Lung cancer, continue with oncology.
7. Breast cancer, no evidence of recurrence at this time.
DISPOSITION: She is going to be discharged home. She will followup with her Dr. ___ [NAME], in approximately 2 weeks and oncology, as per their office.
- English - SraJMcGin, Friday, August 26, 2011 at 9:15pm
"having woke up" is very bad grammar = having awakened..."
not "a 8" but "an eight"
10; currently at admission = 2 sentences joined with a semicolon.
The 2 sentences prior to the last sentence are NOT complete sentences.
However, you might jot notes like that; a formal summary would be more like:
"slightly with no fevers..." She had recent radiation, etc.
Past Medical History is OK with just notes and not complete sentences?
her light headiness was resolved?
1. and/or (usually)
3. well; continue (to avoid a run-on sentence
4. and take enough to stay well dehydrated
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