Report 2 Billie Tree #BT040401CN - At

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Report 2 Billie Tree #BT040401CN - At
Report 2
Name: Billie Tree
#040401
PROBLEM #
1
SUBJECTIVE
Laboratory studies completed.
2
OBJECTIVE
Serum potassium 2.6, aldosterone level 112 (normal 12-36). Computed tomography shows a
3 x 4 cm right adrenal mass. The left adrenal gland is normal in size. Electrocardiogram: Normal
sinus rhythm without premature ventricular contractions or fibrillation.
ASSESSMENT
Hypokalemia and hyperaldosteronism is consistent with Conn’s syndrome. No evidence of
cardiac arrhythmia despite hypokalemia.
PLAN
Intravenous KCl replacement and daily repeat serum potassium, cardiac monitor until stable post
right adrenalectomy.
___________________________________
Sansuk Sudsai, MD
D:
T:
SS:
Foot notes
1
The doctor does not dictate a problem number for this chart note. The problem number is a required field. Add the
heading and timestamp this to flag the doctor. (Rule 52)
2
“Study” is dictated here. Edit to plural context. The OBJECTIVE lists several different studies, or types of tests,
done.
3
Doctor dictates SUBJECTIVE here in error. Edit to correct the heading
4
Numerals and their units of measurement should be together on a line. (Rule 71) Be sure the entire measurement, 3
x 4 cm, is together on the same line.
5
The doctor spells this using the possessive form. OK to type as dictated, since this is clearly the doctor’s preference
here. It would also be acceptable for the course as just Conn syndrome, without the possessive.
6
KCl is the chemical abbreviation for potassium chloride. A brand name for this medication is “Kay Ciel,” which
sounds the same as “KCl” when pronounced. When both the generic and brand names sound the same when
pronounced, always transcribe the generic name.
7
Instead of a comma here, a period would also be acceptable.
3
4
5
6
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