Associate Level Material Medical Report This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook.
Each medical record should be completed and contain two questions you would ask of the potential hires. The following suggestions will help you get started: • Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis. • For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section.
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This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history. • For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness. • For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam.
This includes vital signs or anything observed by performing the patient physical exam. • For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis. • For the Impression/Discussion, indicate the patient diagnosis and what the plan is for his or her. This includes treatment, preventative measure to take, or follow-up. Templates provided on the following pages. Use the following templates for the assignment. Complete each section, save, and then submit as an attachment. Chapter 3 – Medical Record | |History of Present Illness | |This is a 32-year-old Caucasian female was having severe (ab-DAWM-ih-nal) pain on the evening of admission. She was awakened by | |sharp pains in the (gastr/o). She took an (ant-AS-id) before leaving for work and had no relief throughout the day.
She did eat | |lunch and shortly after developed (NAW-see-ah), (emesis), and an hour later she developed watery (dy-ah-REE-ah) with 4 | |(def-eh-KAY-shun) movements over the next few hours. The patient’s (orex/o) changed a couple of weeks ago. The patient complains of| |(dis-PEP-see-ah) after eating spicy foods. Patient denies any history of KROHN disease. By this evening her pain was so severe that| |she came to the emergency room to be seen. | |Past Medical History | |She has a past history of a (hy-AA-tal) (HER-nee-ah) in which a (her-nee-OR-ah-fee) was performed for correction.
A hiatal hernia | |occurs when part of your stomach pushes upward through your diaphragm. Your diaphragm normally has a small opening (hiatus) that | |allows your food tube (esophagus) to pass through on its way to connect to your stomach. The stomach can push up through this | |opening and cause a hiatal hernia (Mayo Clinic, 2011). Patient has a past history of (gas-TRY-tis) and has been instructed from her| |Medical Physician to stop eating spicy foods because this will cause inflammation of the (gastr/o), acid production, or a bacterial| |infection.
Patient also has a past history of (pan-kree-ah-TY-tis) from alcohol abuse in which her Doctor also advised her to stop | |drinking. She said she has a past medical history of (dis-PEP-see-ah) and believes the spicy foods are the cause of severe flare | |ups in the (gastr/o). | |Physical Examination | |Temperature 104. 6, pulse 74, respiratory rate 18 (TPR), blood pressure 164/98 (BP) are measured. She is (AOx3) lying uncomfortably | |in bed.
Abdominal examination: Abdomen is soft. There is tenderness in the (RLQ), (RUQ), and (LUQ). Patient was admitted for | |further observation. NPO was posted on patients chart at time of admission. | |Diagnostic/Lab Results | |Patient had a (cholecyst/o) (SAWN-oh-gram) performed to look into the (gastr/o). She also had an (en-doh-SKAW-pik RET-roh-grayd | |koh-lan-jee-oh-pan-kree-ah-TAWG-rah-fee) (ERCP) (pancreat/o).
Endoscopic retrograde cholangiopancreatography is an imaging test | |that uses an endoscope (a thin, flexible tube with a tiny camera on the end) to view the pancreas and surrounding structures | |(emedicinehealth, 2011). | |Impression/Discussion | |Acute cholecystitis and acute appendicitis. Detail instructions were carried out with patient. Observing her condition and the | |dangers of not following through with surgery and possible complications can arrive was also discussed with the patient.
She agreed| |to follow through with surgery and will be taken to the operating room shortly. | |Two Questions for prospective hires | |Do any family members have a past medical history of (pancreitis)? | |Are there any forms of (KAN-ser) in your family’s medical history in the past or present? | |References | |Retrieved from http://www. emedicinehealth. com/pancrestitis/page5_em. htm#Exams and Tests (ERCP) | |Retrieved from http://www. mayoclinic. om/hiatal-hernia/DS00099 | |Chapter 4 – Medical Record | |History of Present Illness | |This 51-year-old White male was seen in the emergency department on May 21, 2001. Patient did work in the coal mine for 10-years | |and has never been diagnosed with any lung (KAN-ser).
Patient awakened at 7:00 am. He said he was experiencing a little dizziness | |and was (NAW-see-ah). Patient is complaining of (thorac/o) pain. The patient is said to be (hy-PAWK-sik). He is also said to be | |(sy-ah-NAWT-ik). Patient is experiencing (SARS). Severe acute respiratory syndrome (SARS) is a serious form of pneumonia. It is | |caused by a virus that was first identified in 2003. Infection with the (SARS) virus causes acute respiratory distress (severe | |breathing difficulty) and sometimes death (The New York Times Company, 2011).
He also complains of (SOB), patient is also | |experiencing (DISP-nee-ah). Patient stated he believes he is experiencing (AP-nee-ik) while sleeping. Patient admits he feels pain | |in his (RUL) of his lungs when he deep breaths. He said he had been coughing and been having (ek-spek-toh-RAY-shun) sputum from his| |lungs. Patient denies any history of alcohol or drug abuse. He did not take any medication but chose to lye down. Patient said | |after a few hours passed he did not feel any better and the pain in his (thorac/o) was so severe he decided to come to the | |emergency room to be seen. |Past Medical History | |He has a past medical history of (noo-moh-nee-ah) He stated he had developed (brong-ky-tis) at the age of 30-years old. Patient has| |a history of smoking 4 (PPD) of cigarettes per day and has done so for the last 25 years. Patient has experienced (thorac/o) in his| |chest and was advised from his medical Doctor to stop smoking. He has also had an (URI). Patient recently had (CXR) done it showed | |no signs of any lesions. Past surgical history of a (LLL) (loh-BEK-toh-mee) in the remote past.
A lobectomy is a surgical procedure| |in which a lobe of the lung is removed, usually to treat a tumor. The left lung has two lodes, and the right lung has three lopes | |(Lynn Eldridge MD, 2010). | |Physical Examination | |VITAL SIGNS: Temperature 100. 1, pulse 80, respiratory rate 40 per minute (TPR), blood pressure 150/90 (BP). The respirations are | |measured for 1 minute by counting each rise and fall of the (thorac/o) as one breath (CXR) GENERAL: The patient appears | |uncomfortable and in pain.
HEENT: Negative, except for slight cyanosis of the lips. Neck is free of any masses. (thorac/o): | |(aws-kul-TAY-shun) (per-KUSH-un) was performed to listen to breathe sounds. HEART: No murmur and heart sounds normal. ABDOMEN: No | |tenderness. EXTREMITIES: Normal with full range of motion noted. There were no abnormalities’ with the fingers noted. | |Diagnostic/Lab Results | |Patient was delivered 95% oxygen through a nasal (KAN-yoo-lah).
Complete (hemat/o) count showed a white blood cell count of 12,000 | |with 75 segs, 3 bands, and 1 lymph. Sputum was sent to lab for C to identify any bacteria. Saturation of 60% was seen. There were| |some consolidative changes with the (RLL), and no pleural fluid was noted. Focal scarring and inflammation from past (brong-ky-tis)| |is the result of density in the (LUL) and (RUL). A (thorac/o) (ray-dee-AWG-rah-fee) was performed as well as a (PFT). |Impression/Discussion | |(SARS) | |(brong-koh-noo-MOH-nee-ah) | |Double Pneumonia | |Two Questions for prospective hires | |Do any of your family members have a history of (brong-ky-tis) of (AZ-mah)? |Has any family member ever been diagnosed with (lee-jeh-NEL-ah) (noo-moh-FIL-ee-ah)? | |References | |Retrieved from http://www. healthnytimes. com/health/guides/disease/severe-acute-respiratory-syndrome-sars/overview. html | |Retrieved from http://www. lungcancer. about. com/od/glossary/g/lobectomy. htm | Chapter 5 – Medical Record | |History of Present Illness | |The patient is a 70-year-old white female who was transferred via ambulance from home to the emergency department. The patient was | |on her way to the restroom and her daughter noticed once she stood up and took a couple of steps she was no longer moving. Patient | |is experiencing lightheadedness.
She said she sometimes can get (hy-poh-TEN-siv) when she stands up to quick. Patient is | |complaining of (SOB). She has also stated she felt (NAW-see-ah). Patient admits that her (BP) has been higher than normal for the | |last two days but could not remember what her numbers were. Patient is experiencing some discomfort on the left side of her | |(pulmon/o). She stated after she ate she developed a little (dy-ah-REE-ah) with only 2 (def-eh-KAY-shun) movements. The patient | |said she feels slight pain in her (thorac/o) area.
Patient is (AOx3) lying uncomfortable in bed. Patient admits to having pain in | |her right (IL-ee-ak) but has never had a surgery or replacements. Patient denies any history of (KROHN) disease. Patient is also | |experiencing some discomfort in her (ab-DAWM-ih-nal) area. | |Past Medical History | |She has a past history of clog (AR-tee-ee). Arteries are blood vessels that carry blood rich in oxygen throughout your body.
They | |go to your brain as well as to the tips of your toes. Health arteries have smooth inner walls and blood flows through them easily. | |Some people, however, develop clogged arteries. Clogged arteries result from a build-up of a substance called plaque on the inner | |walls of the arteries. Arterial plaque can reduce blood flow or, in some instances, block it all together (WebMD, 2005). Patient | |also had (VEN-yool) which did turn into a large (VAYN). Patient has been diagnosed with poor (sir-kyoo-LAY-shun) in both legs. She | |has a past history of (kar-dee-oh-PUL-moh-nair-ee).
Patient also has a past history of a (brachi/o) (arter/o). She said she has a | |past history of (peh-RIF-eh-ral) (eh-DEE-mah) with both angles. | |Physical Examination | |The patients is lying in bed and unable to follow any commands. Heart: Regular rate and rhythm. There is slight distended in her | |neck veins. (BS) has revealed congestion in (RL). The abdomen is soft. The physical examination shows (eh-DEE-mah) in both legs and| |feet. Temperature: 101. 9, Pulse: 70, respiratory rate 19, (TPR), blood pressure 149/80 (BP). |Diagnostic/Lab Results | |(CXR) was done and shows no signs of lesions. Patient was placed on cardiac monitor and there were findings of a (cardi/o) attack. | |She was administered a low dose aspirin. Patient was admitted for further observation and test. | |Impression/Discussion | |Doctor discussed with patients’ daughter that she had a slight (cardi/o) attack before coming to the hospital.
A heart attack | |happens if the flow of oxygen-rich blood to a section of heart muscle suddenly becomes blocked, Most heart attacks occur as a | |result of coronary heart disease (CHD). CHD is a condition in which a waxy substance called plaque builds up inside the coronary | |arteries’. These arteries supply oxygen-rich blood to your heart. When plaque builds up in the arteries, the condition is called | |atherosclerosis. The buildup of plaque occurs over many years. Eventually, an area of plaque can rupture (break open) inside of an | |artery.
This causes a blood clot to form on the plaque’s surface If the clot becomes large enough, it can mostly or completely | |block blood flow through a coronary artery. If the blockage isn’t treated quickly, the portion of heart muscle fed by the artery | |begins to die. Healthy heart tissue is replaced with scar tissue. This heart damage may not be obvious, or it may cause severe or | |long-lasting problems (National Heart Lung and Blood Institute, 2011). Patient will need to remain in the hospital and she will | |remain on a cardiac monitor. |Two Questions for prospective hires | |How long have you had severe (eh-DEE-mah)? | |Have you ever been diagnosed with (pair-ih-KAR-dee-um)? | |References | |Retrieved from http://www. webmd. com/heart-disease/clogged-arteries-arterial-plaque | |Retrieved from http://www. nhlbi. nih. gov/health/health-topics/heartattack/causes. html |