Explain what happened using everyday language (lay terms). You do not need to rewrite the entire note, but provide an explanation of any medical terms you encounter, 30pts

Dear Dr. XXXXXX: Your patient R was seen today in Otolaryngology consultation as part of an airway clearance prior to upcoming sclerotherapy. HISTORY OF PRESENT ILLNESS: R is a 51 year old female who presents to today’s clinic visit due to history of cervicofacial venous malformation. R has involvement in the right cheek and submandibular regions with extension towards the floor of the mouth based on imaging. R previously has received care in Chicago. She has had four prior sclerotherapies, most recently in 2009. R reports that she tolerated these procedures well to her recollection. She did not require prolonged intubation following the procedures. In general R has no difficulty breathing. She is able to be active without distress. She sleeps well without snoring or apneic concems. She is able to eat and drink without concerns for dysphagia. R has recently been evaluated by Dr. XXXXX in the Vascular Anomalies Center. They are planning to perform sclerotherapy at our institution next week. REVIEW OF SYSTEMS: Has been reviewed with R via the sheet provided to her at clinic check in encompassing 14 systems and is otherwise negative. PAST MEDICAL HISTORY: left-sided cervicofacial venous malformation. PAST SURGICAL HISTORY: Sclerotherapy, most recently 2009. MEDICATIONS: None. ALLERGIES: No known drug allergies SOCIAL HISTORY: R does not smoke and is not exposed to those who do. PHYSICAL EXAMINATION: Pulse 58 beats per minute, oxygen saturation 100% on room air. Temperature 36.8 degrees C. She is not in any pain. Ris seated comfortably in the examination chair. She is breathing comfortably and quietly without stridor or stertor. There is venous malformation involving the left cheek and submandibular regions. Bilateral tympanic membranes and external auditory canals are clear. There is no effusion or otorrhea noted. Nasal passages are patent anteriorly. Septum is midline. Intraoral examination reveals symmetrical palate elevation. Uvula is midline. Tonsils are small. Tongue mobility is normal. Floor of mouth is soft. Dentition is in good repair. There is no evidence of any venous malformation within the oral cavity. Neck examination is otherwise normal with the exception of mild submandibular fullness. PROCEDURE: A flexible nasal endoscopy and laryngoscopy was performed at today’s clinic as part of her airway evaluation. On examination, she was found to have patent nares and septum was midline. Choanae is patent. She has normal nasopharynx, normal hypopharynx, and normal laryngeal examination. There is normal vocal cord function bilaterally. There is no evidence of any venous malformation on flexible endoscopy. IMPRESSION: Venous malformation. RECOMMENDATIONS: Dr. XXXXXXXX and I reviewed our findings with R. R has venous malformation

To begin to prepare you for reading a medical record and medical terminology in the clinical setting you will complete an assignment. You will choose one of two medical sample note and answer the following questions. 1. Why is this person being seen by the physician? What is their medical diagnosis(10 pts)? 2. What medical specialty is seeing this patient(10 pts)? 3. What information is provided about the patient’s medical history (30pts)? In the ENT note-explain in detail what is the “Review of Systems.” 4. Using a paragraph writing format, explain what happened during the visit. Explain what happened using everyday language (lay terms). You do not need to rewrite the entire note, but provide an explanation of any medical terms you encounter, 30pts) Special Instructions for: Question #4 ENT note-Provide explanation for all terms in the note. or Gallbladder note – Please provide explanation for “Patient Profile” (page 1) and “Procedure details which starts at the bottom of page 1 and ends right before “Pathology Specimen” on page 2.