Beginning Medical Transcription (2nd ed.

CARDIOPULMONARY REPORTS ENT AND OPHTHALMOLOGY REPORTS

1. Initial Office Evaluation: Acute bronchitis 1. Office Note: Otitis media, tooth decay
2. Office Note: Bronchitis, upper respiratory infection 2. Office Note: Sinusitis
3. Office Note: Peripheral vascular disease 3. Office Note: Rhinitis
4. Preoperative Note: Tracheostomy 4. Office Note: Failed hearing test
5. History and Physical: Chronic obstructive pulmonary 5. Office Note: Pharyngitis
disease, congestive heart failure, atrial fibrillation 6. Office Note: Otitis media status post ear tube surgery
6. Emergency Department Report: Code Blue, fatal trauma 7. Discharge Summary: Tonsillectomy and adenoidectomy
7. Discharge Summary: Pneumonia, congestive heart failure 8. Office Note: Septal deviation
8. Discharge Summary: Dyspnea 9. Discharge Summary: Exudative pharyngitis
9. Discharge Summary: Bronchitis, chronic obstructive 10. Discharge Summary: Epistaxis
pulmonary disease 11. Discharge Summary: Cellulitis of nasal vestibule
10. Discharge Summary: Adult respiratory distress 12. Preoperative Note: Blind eye
syndrome, sepsis, cardiac arrest 13. Discharge Summary: Retinal tear/cryopexy
11. Discharge Summary: Bronchitis, congestive heart 14. Office Note: Blind eye, for enucleation
failure, death 15. History and Physical: Cataract
12. Consultation: Pleural effusion, pneumopathy 16. Discharge Summary: Glaucoma
13. Discharge Summary: Adult respiratory distress syndrome
14. Discharge Summary: Arteriosclerotic heart disease,
atrial fibrillation
15. Consultation: Ischemic cardiomyopathy GASTROINTESTINAL REPORTS
16. Discharge Summary: Pneumonia, emphysema, arrhythmia
17. Discharge Summary: Status post myocardial infarction 1. Office Note: Irritable bowel
18. Discharge Summary: Pulmonary edema, atrial fibrillation 2. Office Note: Vomiting
19. History and Physical: Angina, coronary artery disease, 3. Discharge Summary: Pancreatitis
for bypass grafting 4. Discharge Summary: Ileus
20. Office Note: Atrial flutter post cardioversion 5. Discharge Summary: Fecal impaction
21. Office Note: Chronic obstructive pulmonary disease, 6. Preoperative Note: Emphysematous gallbladder
status post myocardial infarction 7. Discharge Summary: Ulcer and gangrenous cholecystitis
22. Electrocardiogram Rhythm Strip 8. Discharge Summary: Alcohol-related pancreatitis
23. Discharge Summary: Chronic obstructive pulmonary 9. Discharge Summary: Acute appendicitis
disease, pulmonary fibrosis, cardiomyopathy 10. Discharge Summary: Cholecystitis in pregnancy
24. History and Physical: Cardiac arrest, heart disease, 11. Discharge Summary: Crohn’s disease, abdominal fistulae
ventricular fibrillation 12. Discharge Summary: Prolapsed anus, hemorrhoids
25. Consultation: Pulmonary chest pain 13. Discharge Summary: Cholecystectomy, esophago-
gastroduodenoscopy
14. Discharge Summary: Colitis
15. Discharge Summary: Peptic ulcer disease,
DERMATOLOGY/PLASTIC REPORTS gastrointestinal bleeding
16. Discharge Summary: Upper gastrointestinal bleeding
1. Emergency Department Report: Finger laceration 17. Discharge Summary: Acute appendicitis
2. Letter: Lipectomy 18. Preoperative Note: Liver laceration
3. Office Note: Lip lesion 19. Preoperative Note: Appendicitis, phlegmon
4. Office Note: Atopic dermatitis 20. Preoperative Note: Bile leak
5. Office Note: Acne, pharyngitis
6. Office Note: Nevi
7. Letter: Pendulous breasts
8. History and Physical: Cellulitis of leg
9. Preoperative Note: Thumb graft for burn
10. Office Note: Bullous pemphigoid
11. Discharge Summary: Maxillofacial malformations
12. Discharge Summary: Fibrous histiocytoma
13. Discharge Summary: Cleft lip and palate repair
 Beginning Medical Transcription (2nd ed.)

GENITOURINARY REPORTS NEUROLOGY/PSYCHIATRIC REPORTS

1. Preoperative Note: Groin hernia 1. Office Note: Schizophrenia

2. Preoperative Note: Penile prosthesis 2. Office Note: Headaches, nervous
3. Discharge Summary: Urinary tract infection 3. Office Note: Ventriculoperitoneal shunt
4. History and Physical: Ureteral stone 4. Office Note: Ventriculopleural shunt malfunction
5. Discharge Summary: Bladder tumor 5. Physical Therapy Progress Note: Brain stem infarct
6. Discharge Summary: Inguinal hernia repair 6. Office Note: Schwannoma
7. Discharge Summary: Kidney stone 7. Office Note: Headache history
8. History and Physical: Bladder outlet obstruction 8. Discharge Summary: Agoraphobia
9. Discharge Summary: Pyelonephritis 9. Discharge Summary: Cerebral infarction
10. Discharge Summary: Transurethral resection of the 10. Consultation: Dementia
prostate 11. Consultation: Hydrocephalus
11. Consultation: Perinephric abscess 12. Consultation: Head injury (Comatose)
12. History and Physical: Pyelonephritis 13. History and Physical: Slurring of speech, hypertensive
13. History and Physical: Peyronie’s disease encephalopathy
14. History and Physical: Bulbar urethral stricture 14. History and Physical: Occipital neuralgia
15. History and Physical: Renal insufficiency 15. Discharge Summary: Cerebrovascular accident
16. Discharge Summary: Staghorn calculi 16. Electroencephalogram #1
17. Discharge Summary: Testicular torsion 17. Electroencephalogram #2
18. Discharge Summary: Lacunar infarct
19. Office Note: Psychiatric evaluation
20. Discharge Summary: Altered mental status, confusion,
HEMATOLOGY-ONCOLOGY-IMMUNOLOGY hydrocephalus
REPORTS 21. Discharge Summary: Bipolar disorder

1. Office Note: Melanoma

2. Preoperative Note: HIV positive, Mycobacterium
avium complex OBSTETRICS AND GYNECOLOGY REPORTS
3. Preoperative Note: Liposarcoma
4. History and Physical: Prostate cancer 1. Letter: Ovarian carcinoma follow-up
5. Discharge Summary: Chronic fatigue syndrome 2. Office Note: Dysmenorrhea
6. Discharge Summary: Colon carcinoma 3. Office H&P: Annual check with Pap
7. Discharge Summary: Anemia 4. Office Note: Premature labor
8. Consultation: Mononucleosis 5. Office Note: Status post hysterectomy
9. Discharge Summary: Mesothelioma 6. Office Note: Gardnerella infection
10. History and Physical: Pancreatic cancer 7. Office Note: Vaginosis
11. History and Physical: Bronchogenic carcinoma 8. Preoperative Note: Breech fetus
12. Office Note: Brain tumor 9. Preoperative Note: Decelerations
13. Discharge Summary: AIDS 10. Office Note: Post delivery recheck
14. Discharge Summary: Bone marrow disease 11. Office Note: Post delivery cesarean section recheck
15. Discharge Summary: Leukemia 12. History and Physical: Vaginal infection
13. History and Physical: Term pregnancy in active labor
14. History and Physical: Uterine myomata
15. Discharge Summary: Cervical dysplasia
16. Discharge Summary: Status post delivery
17. Discharge Summary: Menorrhagia
18. Discharge Summary: Status post cesarean section,
diabetes mellitus
19. Discharge Summary: Vaginal hysterectomy with
anterior-posterior repair
20. Discharge Summary: Status post delivery, chronic
hypertension
 Beginning Medical Transcription (2nd ed.)

ORTHOPEDIC REPORTS PEDIATRIC REPORTS

1. Office Note: Osteomyelitis 1. Office Note: Short stature, otitis media

2. Office Note: Shoulder instability 2. Discharge Summary: Croup
3. Office Note: Heel pain 3. Discharge Summary: Head injury
4. Office Note: Shin splints 4. Discharge Summary: Diabetes mellitus
5. Office Note: Below-knee amputation 5. Initial Office Evaluation: Asthma
6. Office Note: Knee pain 6. Discharge Summary: Newborn with hypoglycemia
7. Office Note: Prepatellar bursitis 7. History and Physical: Lymphadenitis, otitis media,
8. Office Note: Meniscal injury pharyngitis
9. Preoperative Note: Trauma with fractures 8. Office Note: Otitis media, diaper dermatitis
10. Discharge Summary: Cervical and lumbar sprains 9. Discharge Summary: Rule out sepsis, viral infection
11. Preoperative Note: Humeral fracture 10. Progress Note: Septic baby
12. Preoperative Note: Arthroscopy 11. Progress Note: Status post cesarean section delivery
13. Preoperative Note: Knee pain) 12. History and Physical: Newborn
14. Preoperative Note: Hip pin removal status post hip 13. History and Physical: Fever, vomiting, rule out sepsis
fracture 14. History and Physical: Carbon monoxide poisoning
15. Preoperative Note: Left lower leg injury
16. Discharge Summary: Sciatica
17. Discharge Summary: Hip fracture
18. Discharge Summary: Back pain APPENDIX
19. Office Note: Cervical radiculopathy
20. Preoperative Note: Gunshot wounds with fractures Quick-Reference List of Beginning Medical Transcription,
21. Preoperative Note: Clavicle fracture 2nd ed., Words and Phrases
22. Consultation: Hip pain
23. Discharge Summary: Ankle fracture
24. Office Note: Lumbar disk herniation
25. Preoperative Note: Fibular shaft fracture INDEX TO MEDICAL REPORTS
26. Physical Therapy Progress Note: Trouble walking
27. Physical Therapy Progress Note: Trouble with mobility
28. Discharge Summary: Open reduction and internal
fixation of femur fracture
29. Discharge Summary: Back and leg pain
30. Discharge Summary: Fractured femur with pinning
 Beginning Medical Transcription (Classic edition)

GUIDELINES FOR BEGINNING MEDICAL DERMATOLOGY DICTATION

TRANSCRIPTION 1. Chart Note: Acne
2. Letter: Allergy evaluation
3. Chart Note: Dermatitis on chest
SAMPLE FORMATS 4. Chart Note: Dermatitis on dorsum of foot
5. Chart Note: Benign skin lesion; malignant melanoma
6. Chart Note: Recurrent urticaria
INTRODUCTORY DICTATION Chart Note: Drug hypersensitivity
7. Chart Note: Tinea versicolor of shoulders, upper chest,
1. The SUM Program Educational Materials, and back
Sally C. Pitman, MA, CMT 8. Consultation: Confluent psoriasis with secondary
2. Letter to Medical Transcription Student, infection
Marilyn Fordney, CMT 9. History and Physical: Cellulitis of arm in IV drug user
3. An Introduction to Medical Transcription, 10. Initial Office Evaluation: Recurrent squamous cell
Vera Pyle, CMT carcinoma of lip
4. Professionalism and the Medical Transcriptionist, 11. Initial Office Evaluation: Eczema, digit and elbow;
Kathy Donneson, MPA chronic localized eczematous dermatitis of chest
5. The Spirit of Medical Transcription, 12. Chart Note: Synovial cyst of toe
Judith Marshall, MA, CMT 13. Chart Note: Trophic ulcer of hip
6. Laughter Is the Best Medicine, 14. Emergency Report: Repair of laceration
Sally C. Pitman, MA, CMT 15. Letter: Treatment of skin cancer
7. Criticism, Marcy Diehl, CMT 16. Chart Note: Plaque psoriasis of scalp and elbows
8. Using Medical References, Sheila Sloane, CMT 17. Discharge Summary: Decubitus ulcer, hip
9. The Importance of Medical Terminology, 18. Consultation: Streptococcus cellulitis, lower extremity
Davi-Ellen Chabner, MAT 19. Chart Notes: Herpes zoster
10. Medical Transcription Equipment, Bruce Tennant, CMT De-epithelialization of oral cavity
11. The Health Record: A Healthcare Responsibility, Hypertrophic scar
Pam Wear, MBA, RRA Atopic eczema
12. Thoughts on Anatomy, Linda C. Campbell, CMT Acute eczematous dermatitis, back and shoulders
13. An Introduction to Medical Specialties, Tinea pedis; onychomycosis
Susan M. Turley, MA, CMT, RN 20. Discharge Summary: Cellulitis and ulceration, lower leg
14. The History and Physical Examination,
John H. Dirckx, M.D.
UROLOGY DICTATION
1. Initial Office Evaluation: Recurrent urinary tract infection
PHARMACOLOGY DICTATION and ureteral scar tissue; laxative abuse; reactive hypo-
Pharmacology and Healthcare, glycemia; recurrent edema
Susan M. Turley, MA, CMT, RN 2. Chart Note: Acute cystitis
3. Emergency Report: Urinary tract infection
4. Chart Note: Nephrolithiasis
LABORATORY PROCEDURES DICTATION 5. History and Physical: Ureteral stone with obstruction
Laboratory Tests: Their Function and Importance, 6. Initial Office Evaluation: Hematuria due to passage of
James L. Bennington, M.D. renal stone
7. Consultation: Ureteral lithiasis with partial ureteral
obstruction and hydronephrosis
8. Discharge Summary: Chronic renal failure with uremia
9. History and Physical: Urinary stress incontinence
10. Chart Note: Status post adenocarcinoma of prostate;
metastatic disease of shoulders
11. History and Physical: Urinary frequency with discharge
and dysuria; prostate nodule
12. Chart Note: BPH with bladder outlet obstruction;
bladder diverticulum
13. History and Physical: Benign prostatic hypertrophy; pos-
sible bladder tumor or stone within bladder diverticulum
 Beginning Medical Transcription (Classic edition)

UROLOGY DICTATION (continued) ORTHOPEDIC DICTATION

14. History and Physical: Recurrent bladder neck obstruction 1. Chart Note: Pain in metatarsal area; probable Morton’s
15. Chart Note: Hypospadias; circumcision; rule out chordee neuroma
16. Chart Note: Vasectomy 2. Chart Notes: Painful bunion; painful arch of foot
17. History and Physical: Urethral stricture disease Traumatic cyst of ankle. Knee pain.
18. Consultation: Polyuria with hyposthenuria; possible Knee pain with chip or accessory bone
diabetes insipidus and Bartter’s syndrome 3. History and Physical: Patellar malalignment syndrome
19. Chart Note: Phimosis with patellar tilt
20. Chart Note: Phimosis with adhesions 4. Chart Note: Painful knee; marginal spurs at the
21. Discharge Summary: Radiation cystitis; carcinoma of patellofemoral joint; possible torn meniscus
prostate; ileal conduit; inguinal hernia repair 5. Discharge Summary: Hemarthrosis; anterior cruciate tear
22. Discharge Summary: Hydronephrosis; possible ureteral and osteochondral fracture of femoral condyle, knee
obstruction and horseshoe kidneys 6. Letter: Avascular necrosis of hip, status post total hip
23. Chart Note: Probable urethritis arthroplasty
7. Consultation: Arthralgias of neck, elbow, knee, and
ankle; possible rheumatic syndrome
GASTROENTEROLOGY DICTATION 8. Chart Note: Fibrositis or costochondritis
1. Chart Note: Gastroscopy follow-up Chart Note: Herniated disk
2. Chart Note: NSAID-induced peptic ulcer disease 9. Chart Note: Back and hip pain
Chart Note: Stomach ulcer disease 10. Chart Note: Back pain; post lumbar epidural injection
3. Consultation: Vomiting; heartburn; irregular periods; Chart Note: Lumbosacral sprain
mood swings 11. Chart Note: Osteoporosis follow-up
4. Letter: Midepigastric discomfort and nausea 12. Letter: Cervical disk herniation
5. History and Physical: Postprandial epigastric distress; 13. Letter: Neck pain; exostosis, base of skull
tumor mass, greater curvature of stomach 14. Chart Note: Status post ganglionectomy, wrist
6. Chart Note: Acute viral gastroenteritis with dehydration 15. Chart Note: Recurrent bursitis/tendinitis arm
7. Emergency Room Report: Cholelithiasis; pyelonephritis; 16. Chart Note: Bursitis of arm
gastroenteritis 17. History and Physical: Contusion of ulna, hand, and wrist
8. Discharge Summary: Chronic cholecystitis with 18. Chart Note: Status post fracture of arm
cholelithiasis Chart Note: Status post fracture of shoulder with
9. Chart Note: Liver dysfunction; inflammatory bowel adhesive capsulitis
disease Chart Note: Status post fracture of humerus
10. Consultation: Chronic liver disease, non-A, non-B Chart Note: Status post repair of ulnar collateral liga-
11. History and Physical: Acute appendicitis ment of thumb
12. Consultation: Ileus, differential diagnosis Chart Note: Follow-up of pain of distal radial ulnar joint
13. Chart Note: Severe constipation 19. Discharge Summary: Nonunion fracture of radius, status
Chart Note: Colonic polyp, with history of Hemoccult- post gunshot wound
positive stools; fatigue; upper respiratory infection 20. Emergency Report: Sutured laceration, radial aspect of
Chart Note: Primary biliary cirrhosis; irritable bowel index finger
syndrome; esophageal reflux
14. Letter: Colonoscopy follow-up; sliding-type hiatal hernia
15. Initial Office Evaluation: Chronic fatigue syndrome; CARDIOLOGY DICTATION
weight loss; change in bowel habits; nocturia; possible 1. Chart Note: Hypercholesterolemia with adequate HDL;
toxic work environment reactive hypoglycemia; insomnia; premenstrual syndrome
16. Letter: Irritable bowel syndrome; possible Meckel’s 2. Letter: Weakness following GI bleeding; rapid heartbeat
diverticulum 3. Initial Office Evaluation: Angina pectoris; myocardial
17. History and Physical: Internal-external hemorrhoids with ischemia; heart murmur
thrombosis and gangrene 4. History and Physical: Chest pains; possible musculo-
18. Discharge Summary: Upper GI bleed secondary to ligamentous sprain in costal area
gastric ulcer; anemia 5. Chart Note: Chest pain, probably musculoskeletal
19. Discharge Summary: Primary adenocarcinoma of herni- 6. Consultation: Angina pectoris; hypertension;
ated gastric cardia with extension to esophagus and atherosclerotic peripheral vascular disease
hepatic metastases; alcoholic cirrhosis; hiatus hernia; 7. Chart Note: Atherosclerotic coronary artery disease;
esophagitis unstable angina
 Beginning Medical Transcription (Classic edition)

CARDIOLOGY DICTATION (continued) ENDOCRINOLOGY DICTATION

8. History and Physical: Probable angina pectoris; rule out 1. History and Physical: Chronic fatigue; burning eyes;
myocardial infarction; congestive heart failure, compen- depression; possible hypothyroidism; constipation and
sated; hypertension; arteriosclerotic heart disease diarrhea
9. Consultation: Inferior wall infarction with residual sinus 2. Discharge Summary: Colloid goiter; thyroidectomy
bradycardia; hypertension 3. Chart Note: Hyperthyroidism
10. Chart Note: Palpitations; hypertension 4. Chart Note: Facial and neck edema
11. Initial Office Evaluation: Hypertensive cardiovascular Chart Note: ACTH injection
disease with left ventricular hypertrophy, mitral insuffi- 5. Discharge Summary: Addison’s disease; inguinal hernia
ciency, and congestive heart failure; arteriosclerosis repair
obliterans of lower extremities 6. Chart Note: Hypothyroidism
12. Consultation: Congestive heart failure; atrial fibrillation; 7. Chart Note: Follicular adenoma of thyroid with Hurthle
pleural effusion cell change
13. Chart Note: Myocardial infarctions; sinus tachycardia 8. Discharge Summary: Diabetic ketoacidosis; type I
14. Chart Note: Unstable angina; hypertension; congestive diabetes mellitus; bronchitis and gastroenteritis; mild
heart failure dehydration
15. Chart Note: Atrial fibrillation 9. Chart Note: Non-insulin-dependent diabetes mellitus;
16. Chart Note: Arterial hypertension; probable pacemaker hypertension
malfunction 10. Initial Office Evaluation: Diabetes mellitus type II; con-
17. History and Physical: Myocardial infarction; permanent gestive heart failure; hyponatremia; chronic renal failure
ventricular pacing 11. Emergency Room Report: Diabetes mellitus; dehydration;
18. Chart Note: Coronary artery disease; venous electrolyte imbalance
insufficiency; hypertension 12. Consultation: Diabetes mellitus type II; hypoglycemia;
19. Discharge Summary: Labile hypertension with transient hyperkalemia
focal neural symptoms
20. Emergency Report: Ventricular arrhythmia; alcoholism;
hepatic insufficiency OBSTETRICS AND GYNECOLOGY
21. Initial Office Evaluation: Hypertensive cardiovascular 1. Chart Note: Normal gynecologic examination
disease 2. Letter: Results of Pap smear
22. Chart Note: Raynaud’s disease 3. Chart Note: Herpes simplex virus infection
4. Chart Note: Routine gynecologic examination
Chart Note: IUD insertion
5. Discharge Summary: Cystocele with urinary incontinence
PULMONARY MEDICINE DICTATION 6. Chart Note: Normal gynecologic examination;
1. Chart Note: Intrinsic asthma; skin testing oligomenorrhea
2. Chart Note: Difficulty breathing, with normal PFTs Chart Note: Vesicovaginal fistula
3. Letter: Emphysema; cardiac arrhythmias Chart Note: Complex cystic ovary
4. Consultation: Disability evaluation; reactive airways 7. Discharge Summary: Pelvic inflammatory disease
disease; chronic asthma 8. History and Physical: Symptomatic pelvic relaxation with
5. Emergency Room Report: Laryngotracheal bronchitis; hypertrophic cervicitis; cystourethrocele; uterine descen-
bronchial asthma sus; rectocele: enterocele
6. Chart Note: Small-cell carcinoma of the lung; metastases 9. History and Physical: Menometrorrhagia secondary to
to the brain, abdomen, adrenals, and mediastinum fibromyomata
7. History and Physical: Lower lobe pneumonia refractory 10. History and Physical: Pelvic inflammatory disease;
to treatment endometriosis
8. Consultation: Hypersensitivity pneumonitis or 11. Chart Note: Large-cell carcinoma of cervix
Mycoplasma pneumonia Chart Note: Normal gynecologic examination
Chart Note: Galactorrhea
Chart Note: Hormone replacement therapy
12. Discharge Summary: Adenofibroma of ovaries; follicular
cyst of ovary; cystitis
13. History and Physical: Uterine prolapse; cystocele;
rectocele
14. Chart Note: Twin gestation at 36 weeks with possible
mild pregnancy-induced hypertension
 Beginning Medical Transcription (Classic edition)

OBSTETRICS AND GYNECOLOGY (continued) OPHTHALMOLOGY DICTATION

15. History and Physical: Incomplete abortion 1. Consultation: Corneal abrasion
16. Chart Note: CIN-III (cervical intraepithelial neoplasia) 2. Chart Note: Impaired visual acuity secondary to cataracts
17. Discharge Summary: Repeat low transverse cervical and diabetes mellitus; hypertension
cesarean section and incidental appendectomy Chart Note: Exotropia with overacting inferior obliques
18. Chart Note: Cervical dysplasia; pregnancy 3. Initial Office Evaluation: Macular degeneration; asthma
19. Chart Note: Intrauterine pregnancy, with hyperemesis 4. Initial Office Evaluation: Hard exudates in eye; macular
gravidarum and urinary tract infection edema
20. Chart Note: Pediatric evaluation status post cephalopelvic 5. Chart Note: Bacterial conjunctivitis
disproportion 6. Discharge Summary: Cytomegalovirus retinitis;
21. Discharge Summary: Intrauterine pregnancy, delivered molluscum contagiosum
22. Discharge Summary: Intrauterine pregnancy, delivered; 7. History and Physical: Cataract; pseudophakia;
periurethral tear dermatomyositis; rheumatoid arthritis
23. Letter: Probable residual fibrocystic disease of breast; 8. Discharge Summary: Status post vitrectomy, lensectomy
status post bilateral subcutaneous mastectomy and gas-fluid exchange
24. Discharge Summary: Infiltrating ductal carcinoma of 9. Discharge Summary: Retinal detachment; pseudophakia;
breast; modified radical mastectomy corneal edema; macular degeneration
10. History and Physical: Cataract; pseudophakia;
hypertension
OTORHINOLARYNGOLOGY (ENT) DICTATION
1. Chart Note: Otitis media
2. Chart Note: Serous otitis, decreased nasal airway second- NEUROLOGY DICTATION
ary to adenoid hypertrophy, and tonsillar hypertrophy 1. Consultation: Hemiparesis
3. Chart Note: Lightheadedness and nasal congestion 2. Letter: Seizures
4. Chart Note: External otitis 3. Consultation: Seizures
Chart Note: Serous otitis 4. Chart Note: Memory loss; dementia
Chart Note: External otitis 5. Chart Note: Bacterial meningitis
5. Letter: Inadequate nasal airway, deviated nasal septum, 6. History and Physical: Viral meningitis; migraine
possible rhinitis headaches
6. Letter: Negative ENT examination 7. Discharge Summary: Degenerative cervical disk disease
7. Emergency Report: Epistaxis with radiculopathy at C5-6
8. Chart Note: Nasal polyps; sinusitis 8. Letter: Herniated L4-5 disk
9. Chart Note: Postauricular mastoid wound infection 9. Chart Note: Back pain
10. Consultation: Allergic rhinitis with hypertrophy of 10. Consultation: Arm pain; normal upper extremity on
turbinates, deviated nasal septum, and inadequate nasal EMG/NCV study
airway 11. Chart Note: Parkinsonism
11. Chart Note: Positive allergy skin tests 12. History and Physical: Cerebral arteriosclerosis; stroke;
12. Chart Note: Streptococcal pharyngitis carotid artery plaquing; pernicious anemia; inguinal
13. Letter: Wharton’s duct dilation for submandibular gland hernia; congestive heart failure
enlargement 13. Consultation: Diabetic neuropathy and postural
14. Chart Note: Lymphoid hyperplasia of tonsillar fossas and hypotension
nasopharynx 14. Initial Office Evaluation: Abducens muscle weakness;
15. Chart Note: Dysphagia with odynophagia possible myasthenia gravis
16. History and Physical: Tinnitus 15. Discharge Summary: Concussion; cervical sprain;
homonymous hemianopsia
16. Emergency Report: Seizures; ventriculoperitoneal shunt

ABBREVIATIONS

LABORATORY GLOSSARY