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 7