We did do a CBC yesterday which did reveal an MCV elevated at 102.1 but did not show any significant anemia. The BMP, however, did show a sodium low at 132, potassium low at 3.0, chloride low at 94, BUN was high at 36, creatinine was high at 1.8, and the calcium was a little low at 8.3. This gentleman states he is feeling much better today he states he did sleep all night last night, which was the first time in over a week. He denies any problems with chest pain, no palpitations, headache, dizziness. He still has an occasional dry cough. Patient also has a history of coronary artery disease. He has had coronary artery bypass grafting of four vessels and did have a PTCA. He also has a history of hyperlipoedmia.
Peter H
Not bad. I would put a semicolon instead of a comma, and insert an 'or': "He denies any problems with chest pain; no palpitations, headache, or dizziness. "
Hyperlipidemia is the correct spelling.
If you took that from dictation, it's not an impressive report. The present condition should come first, followed by history, followed by clinical findings, followed by lab findings.
Adriana Azure
I would report it like this:
This is a __ year old man with chief complaint ___, hospital day ___, with past medical hx CAD s/p CABG x4 (year ___) and PTCA (year ___). No overnight issues, no new complaints, asides from occassional dry cough. Vital signs stable. (And then you report the labs). CBC showed normal white count, but elevated MCV at 102. Sodium was decreased at 132, potassium 3.0, Cl 94. BUN over creatinine is 36/1.8. Calcium 8.3. (Then proceed to medications)
Orignal From: How is my sentence structure? Do I have punctuation mistakes? (medical notes)?
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