Medical project

Files for Required Transcription Assignment 2/Editing Assignment 1 - Chart Notes 16 and 17 - Edit This File.docx

Chart Notes 16 and 17

This is a follow-up note on Kimball Sutor the third.

Kimball Sutor III

Current date The patient did not tolerate 2-1/2 mestinon q.4 h. and stepped back to 2 tablets or 120 mg q.4 h. He feels that he is growing gradually stronger and has become able to walk on a flat heel without having the ankle turn inside or outside; he seems definitely stronger than the last visit: deltoids being fair, biceps good, triceps fair to fair plus. The casual gait is normal. There is mild joint pain throughout. I continue to investigate the possibility of obtaining trans-cervical thymectomy for the patient in this part of the state.

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Nelson G. Black MD

This is an initial chart entry on Charlotte Tup dictated by Dr Mary Norton.

Charlotte Tup Age: 23

Current date This is a 23-year-old, gravida zero white female Mayview College

graduate student whose last menstrual period was March 31, current year. She is on Orthonovum 1/50 and has been on same for the past three years. She complains of vaginal discharge without itching, burning, or odor and of several small, very painful “sores” on the vulva, present for the past six days, which are getting better. There are also several tender enlarged lymph nodes in the right inguinal area and some discomfort in the upper legs. Apparently, the patient has had very little problem with her periods and admits to three different contacts, none of whom have had specific complaints. She is on no other medications. She has had no serious illnesses, no previous surgery, and no allergies.

EXAMINATION: Well-developed, well-nourished white female. There is no CVA tenderness. There is some suprapubic tenderness. Pelvic and rectal examinations reveal several small vesicular tender lesions on the upper vulva bilaterally, grossly consistent with herpes. There are a few enlarged tender nodes in the right inguinal area. The vagina has a fair amount of discharge. The cervix is clean and somewhat tender. The uterus is anteflexed and slightly tender. The adnexum are within normal limits. The bladder and urethra are quite tender.

IMPRESSION: 1) Herpes progenitalis. 2) Vaginitis. 3) Cystitis.

A clean-catch urine was done and revealed many white cells. Vaginal cultures were performed, and the patient was given a prescription for kenalog with orabase for the apparent herpes. Further therapy will be dependent on the results of the cultures. Discussion was then held regarding the lifestyle and the risks involved.

student’s initials Mary A. Norton, MD