This is what I do all day.

This may or may not interest you. Most of you know I type dictated medical reports day after day in hopes of becoming good enough at it to earn some money from home. It's not easy. In fact, it's pretty difficult a lot of the time to understand what the doctor is saying. Some of them are brainless and dictate with food in their mouthes, or let the phone ring right in the recorder without bothering to stop talking. I can only guess at what they are saying when they do this. Some of them talk at the speed of an auctioneer, and others like to cut off the ends of their words. Anyway, I copied and pasted one of the reports I did so you can all see the stuff I do. This was actually a fairly easy one. I'm sure you've never seen a medical report, so maybe this is interesting. Or maybe not. It's a slow blog day. The blanks are names or dates and are left confidentiality purposes.



Rheumatology progress note.

LIST OF PROBLEMS:
1. Rheumatoid arthritis.
2. Emphysema.

MEDICATIONS: Methotrexate 10 mg per week on Monday, prednisone 5 mg daily, Nasacort, Zantac 150 mg b.i.d., Tylenol p.r.n., Paxil 20 mg per day.

LABORABORY DATA:___: Creatinine 1.4, albumin 4.2, AST 25, ALT 15, CBC unremarkable, sedimentation rates 51.

Chest x-ray shows moderate diffuse emphysema. Today’s patient has no complaints in regard to his arthritis. When he saw me 6 weeks ago he had a flare of his RA. His methotrexate was increased from 7.5 to 10 mg per week. His prednisone was increased from 3 mg to 10 mg per day for 5 days. The patient today states that his RA is doing well. He has no complaints of swelling. He denies any shortness of breath, chest pain, fevers, or chills while on methotrexate.

Starting yesterday he has developed a dry cough along with myalgias and congestion-type symptoms of his head and nose. He took his methotrexate Monday. He denies any nausea, vomiting, or diarrhea.

PHYSICAL EXAMINATION: There are no oral ulcers. The lungs are clear with no wheezing or crackles. Heart: Regular rate and rhythm. There is essentially no synovitis on examination today. There are no vasculitic lesions or rashes.

IMPRESSION:
1. Rheumatoid arthritis. He is stable on his current medications.
2. Because methotrexate can induce a cough and even a pneumonitis, I told him not to take methotrexate next week. It told him I will give him Sudafed for his postnasal drip and congestion symptoms. I told him if his symptoms should worsen or if he gets short of breath, cough worsens, or should he develops a fever, see his closest physician as soon as possible.
3. I will obtain a CBC panel and a liver panel today to monitor methotrexate toxicity.
4. Because of his chronic obstructive pulmonary disease by history, I will obtain baseline pulmonary function tests as well. He will follow up in two weeks for reevaluation.