REASON FOR REFERRAL Referred for blisters and rash of mucous membranes and skin.

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1 Report 1 Listen to the audio to fill in the blanks. Name: DERMATOLOGY CONSULTATION REPORT REASON FOR REFERRAL Referred for blisters and rash of mucous membranes and skin. HISTORY OF PRESENT ILLNESS Rash developed inside mouth, then bumps appeared under skin at various places. Oral lesions painful after rupture. PAST HISTORY Habits: No smoking, drinking or drug use. Medications: None. Illnesses: UCD. Operations: None. ALLERGIES: ALLERGIC TO. Social history: Patient is an investigative reporter. Recent travels include Iran and China. Has recently returned from Brazil 1 week before onset of symptoms. Family history: Noncontributory. REVIEW OF SYSTEMS Skin: Other than HPI, no complaints. Hair: No alopecia. Cardiorespiratory: No murmurs, palpitations. Gastrointestinal: No diarrhea, nausea, vomiting. Genitourinary: No dysuria or. Neuropsychiatric: No seizures or headaches. PHYSICAL EXAMINATION GENERAL: The patient is a thin, quiet -year-old black male in no acute distress. VITAL SIGNS: Pulse: 66, regular. Blood pressure: 122/78. Respiratory rate: 20, regular. Temperature: 99.4 F. CONTINUED 44-22

2 Integumentary System Name: DERMATOLOGY CONSULTATION REPORT Page 2 HEENT: Head:. Eyes: EOMs intact. Funduscopic examination normal. Ears: Tympanic membranes clear. Nose: Mucous membranes clear. Mouth: Multiple tense and flaccid bullae scattered throughout the buccal mucosa and mucosa. There are interspersed areas of erosion. NECK: Supple. No adenopathy. CHEST: Clear to auscultation and percussion. ABDOMEN: Soft and flat. No organomegaly or inguinal. GENITALIA: Normal male genitalia. Testicles descended. RECTAL: No prostate enlargement. Stool negative. No blood on the examining glove. EXTREMITIES: Multiple ruptured in various stages are seen, from raw and denuded to crusted. NEUROLOGIC: DTRs normoreflexive. Cranial nerves are intact. DATABASE CBC normal. Chest film clear. Skin biopsy shows suprabasal epidermal cell separation. Positive IF test for epithelial cell surface. ASSESSMENT Rule out toxic epidermal, bullous contact dermatitis and erythema multiforme. RECOMMENDATIONS Review skin biopsy and test. Begin prednisone 60 mg until diagnosis confirmed. If new lesions still appear after days, consider hospitalization and use of immunosuppressive medications. Robert Snow, MD D: (yesterday s date) T: (today s date) RS:(your initials) 44-23

3 Report 2 Listen to the audio to type the report from beginning to end. Use the completed report to determine the correct diagnosis and procedure codes, and then use the MedLook software with the encounter form below to complete a claim for the service. You will use the dictated date as the service date, and it is an office visit for an established patient. Robert Snow, MD NPI: Park Circle EIN: Eugene OR Participating provider Yes No (541) Patient Information Name Carrie Bloom Date of Birth 11/22/1971 Address 542 Main Street Sex F Marital Status Married City Eugene State OR ZIP Home Phone (541) Employment Information Name of Employer Market Foods Address City State ZIP Phone Student Full time Part time If minor, name of school Insurance Information Primary Insurance Secondary Insurance Name Mountain States Name ID# ID# Group# B44 Group# Address 1801 SW Vine Street Address City Denver City State CO ZIP State ZIP Primary Insured Name Secondary Insured Name Relation to Patient self Relation to Patient DOB DOB Employer Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me. Carrie Bloom Signature of patient (or parent of minor child) I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me. Signature of patient (or parent of minor child) Physician signature: Robert Snow, MD Today s Charge Cash/Check 0.00 Balance

4 Integumentary System Report 3 Listen to the audio to fill in the blanks. Name: HISTORY CHIEF COMPLAINT Rash and itch in the left groin. HISTORY OF PRESENT ILLNESS Has had jock itch in the past, treated with. PAST HISTORY Medications: See HPI. Illnesses: Measles, mumps, chickenpox. Operations: _ at age years secondary to trauma. ALLERGIES: NONE. REVIEW OF SYSTEMS Noncontributory. PHYSICAL EXAMINATION GENERAL: The patient is a 26-year-old male who appears well developed and well nourished. VITAL SIGNS: Normal. HEENT: PERRLA. EOMs intact. CHEST: Heart: Normal. Lungs: Clear. ABDOMEN: NBS. No. GENITALIA: Secondary changes in the left inguinal fold are seen with. Diffuse _. RECTAL: Normal. Stool guaiac negative. NEUROLOGIC: DTRs intact. Cranial nerves 2-12 intact. IMPRESSION Cannot exclude candidiasis or infection. CONTINUED 44-25

5 Name: Page 2 PLAN Microsize _ 250 mg p.o. t.i.d. Wood light examination. Culture for yeast infection to rule out. If candida present, switch to ketoconazole and follow with liver function tests. Marikit Makabuhay, MD D: (yesterday s date) T: (today s date) MM:(your initials) Report 4 Listen to the audio to type the report from beginning to end

6 Integumentary System Report 5 Listen to the audio to fill in the blanks. Name: Dr Anne Jones HISTORY CHIEF COMPLAINT The patient presents with a facial rash. HISTORY OF PRESENT ILLNESS The patient, a 31-year-old female, has noticed a developing rash over the portion of the face for the past month. She has noticed a change in her personality, becoming more combative and argumentative. PAST HISTORY Habits: Smokes 1 pack of cigarettes per day. Drinks 1-2 cocktails per week. Medications: The patient takes per day for arthritic pain. Illnesses: UCD. Operations: Appendectomy at age 5 without complications. ALLERGIES: PATIENT ALLERGIC TO. Social history: The patient works as a secretary in an import firm. Her work consists of answering telephones and typing in a very busy office. Family history: _. REVIEW OF SYSTEMS Skin: The patient reports changes in the color of her hands when it is cold, and photosensitivity. Hair: The patient has noticed hair loss for the past year. HEENT: Noncontributory. Cardiorespiratory: Noncontributory. Gastrointestinal: Noncontributory. Genitourinary: Urine cloudy. Gynecologic: Noncontributory. Neuropsychiatric: No history of seizures, head trauma or difficulty walking. There has been no change in her ability to type rapidly. Musculoskeletal: Noncontributory. PHYSICAL EXAMINATION VITAL SIGNS: Within normal limits. CONTINUED 44-27

7 Name: Dr Anne Jones Page 2 HEENT: There is a prominent butterfly rash present. CHEST: Clear to percussion and auscultation. ABDOMEN: The abdomen is soft and nontender. Normal bowel sounds. No. PELVIC: Examination deferred. EXTREMITIES: There is full range of motion in the joints. However, there is mild tenderness in both carpal joints and the left knee. Pulses are 3+ and equal bilaterally. NEUROLOGIC: are normoreflexive and equal bilaterally. IMPRESSION 1. Rule out. 2. Probable. 3. Rule out nephritis secondary to systemic lupus erythematosus. 4. Personality change, most likely secondary to systemic lupus erythematosus. PLAN 1. Admit to for evaluation. 2. If evaluation positive, begin prednisone. Anne Jones, MD D: (yesterday s date) T: (today s date) AJ:(your initials) 44-28

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