Language Skills Worksheet #10

Often, when documenting a patient's objective findings, a dictating doctor will use incorrect medical terminology in such a way as to defy anatomical standards.

Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"She showed good cognitive function without any cognitive functions."

Diagnosis:

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Corrected Text:

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"HEENT exam is completely and entirely normal except for total alopecia and patient is blind."

Diagnosis:

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Corrected Text:

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"Status post left prostatic knee surgery six weeks ago."

Diagnosis:

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Corrected Text:

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"The patient also underwent a left third foot metatarsal head resection."

Diagnosis:

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Corrected Text:

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"Her anal temperature was 98.2 orally."

Diagnosis:

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Corrected Text:

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"Extremities: Speech intact per husband."

Diagnosis:

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Corrected Text:

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"Extremities: Normal. No edema, no jugular venous distention."

Diagnosis:

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Corrected Text:

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"Extremities reveal mild tremulousness but no tongue wag noted."

Diagnosis:

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Corrected Text:

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"The patient had ulnar deviation of the left ankle."

Diagnosis:

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Corrected Text:

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"Pulses absent bilaterally, more so on the right."

Diagnosis:

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Corrected Text:

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"Ear examination: The genitals were......"

Diagnosis:

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Corrected Text:

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"Neuro is within tact."

Diagnosis:

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Corrected Text:

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"The abdomen was without liver, kidney, or spleen."

Diagnosis:

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Corrected Text:

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"Cardiac: Decreased bowel sounds."

Diagnosis:

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Corrected Text:

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"The patient is alert and cooperative, although asleep."

Diagnosis:

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Corrected Text:

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"The patient was in her right lower quadrant."

Diagnosis:

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Corrected Text:

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"The cervix was noted to be 140 and high."

Diagnosis:

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Corrected Text:

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"The left breast had no skin, contour changes, nipple inversion, or masses palpated."

Diagnosis:

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Corrected Text:

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"Head: Acephalic, atraumatic."

Diagnosis:

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Corrected Text:

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"Patient complains of numbness with standing in the posterior buttocks and low back."

Diagnosis:

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Corrected Text:

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"Neck: Trachea was midline, no hepatosplenomegaly."

Diagnosis:

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Corrected Text:

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"He had obvious jugular venous distention in both necks but he was lying horizontally at the time."

Diagnosis:

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Corrected Text:

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