Re: I hope you can take the time to help with this transcription

[Guest guest]

This a lot, but the first thing that I see is " despite my instructions at

discharge to have that *been* done should either have the word *been* taken

out or be changed to " being " done. On the blanks following it is impossible

to even guess without sound-likes. It should be " regimen " (regiment is a

military unit). A verb is missing after " She can passively " but I have no

idea without a s/l. There is another verb missing in " She is able to ___

deltoid. I have no idea what the remaining blanks are. Maybe if you

listed them with s/l if would help. I am going to quit working in about an

hour or so.

I hope you can take the time to help with this transcription

> This is my new client whom I wrote was so good at the beginning of my

> transcription two days ago. Now I just can't slow him down enough. Can

> you read this, fill in the blanks with what you think he might be saying

> and question what you think he might not have said. I really would

> appreciate it. I can't thank you enough for any help you can give me...

> Aliceanne

>

> HIST: Patient is about 2 months status post right shoulder

> hemiarthroplasty, open reduction and internal fixation with a sliding hip

> screw of the right hip. She is now in her second post op visit. On her

> last visit I increased her motion and strengthening of her right shoulder

> which was not being done despite my instructions at discharge to have

> that been done. She has no complaints in regards to but

> still feels that her shoulder is weak. She is going to be going home this

> Saturday and would like to know what her treatment regiment should be.

> EXAM: She has full internal and external rotation passive range. She can

> passively

> between 30 to 100 degrees without pain. Incision is well healed. Her

> distal strength in the arm is good but very weak in the region of the

> deltoid. She is able to deltoid but is not able to hold her arm up.

> Examination of her right hip shows there is full passive range of motion

> without pain. There is no pain with actual Her

> incision is well healed.

> X-RAYS X-rays of the right hip show in the trochanteric a fracture which

> is healed.

> ASSESSMENT 1) healed enteric fracture, right hip 820.21

> 2) Status post hemiarthroplasty, right shoulder 812.01

> PLAN: She will go home this Saturday and we will get her into

> occupational therapy for strengthening of her right shoulder. She can use

> a regular walker at this point and she has no precautions other than deep

> training for her lower extremity. I will see her back in 2 months at

> which time we will get new x-rays of both the hip and the shoulder.

>

> /aas

> 12/28/2000

>

>

> PLEASE VISIT THE NMTC WEB SITE - http://go.to/nmtc

>