Practice Sheet 5 W-MT (written 5) Convert the below dictated lines into Preoperative History and Physical Report transcription with appropriate format of chart note including headings and all the rules of chart note transcription the sixty seven year old gentleman underwent ultrasound guided needle biopsy of the prostate during the trans rectal ultrasound a positive bladder mass was noted he is now to undergo a cystoscopy for confirmation current medications includes cardura four milligram by mouth every hour multiple vitamins Aspirin, lipitor allergies plant pollen past medical history hypertension past surgery transectomy and removal of lymphoma physical examination he appears well alert and oriented vital signs blood pressure one sixty seven over seventy nine pulse seventy respiration eighteen lungs clear heart rhythm is regular without murmur abdomen soft without masses or tenderness groin is normal. extremities no peripheral edema digital rectal exam(DRE) the prostate was smooth with benign consistency diagnosis possible bladder tumor .

1. Practice Sheet 5 W-MT (written 5)
Convert the below dictated lines into Preoperative History and Physical Report transcription with
appropriate format of chart note including headings and all the rules of chart note transcription
the sixty seven year old gentleman underwent ultrasound guided needle biopsy of the prostate
during the trans rectal ultrasound a positive bladder mass was noted
he is now to undergo a cystoscopy for confirmation
current medications includes cardura four milligram by mouth every hour multiple vitamins
Aspirin, lipitor
allergies plant pollen
past medical history hypertension
past surgery transectomy and removal of lymphoma
physical examination he appears well alert and oriented
vital signs blood pressure one sixty seven over seventy nine pulse seventy respiration eighteen
lungs clear
heart rhythm is regular without murmur
abdomen soft without masses or tenderness
groin is normal.
extremities no peripheral edema
digital rectal exam(DRE) the prostate was smooth with benign consistency
diagnosis possible bladder tumor