15 Jun Question Patient Documentation Analysis (graded)
Question
Patient Documentation Analysis (graded)
Class, in this thread we will be looking at patient documentation and patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in Terminal Course Objectives (TCOs) 1 and 2. You must address all of the questions located after the example of surgical history and patient encounter of Darryl McFadden.
SURGICAL HISTORY
History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and vomiting. The initial onset of the pain was about 48 hours prior to presentation. The pain was progressive in nature and began radiating to the back. Late yesterday, the patient drank some Alka-Seltzer and went to bed. He was awakened during the night by the pain and began vomiting. The patient states the pain is constant and has localized to the right lower quadrant. His last bowel movement yesterday afternoon was normal. He does have a history of irritable bowel syndrome; however, he states that this pain is different than the pain he has had in the past.
Past Medical History: Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable.
Past Surgical History: Tonsillectomy and adenoidectomy in early childhood; umbilical hernia repair at age 4.
Medications: None
Allergies: No known drug allergies
Social History: The patient is employed as a computer programmer. He is married and has no children. He has smoked a half a pack of cigarettes daily for the last 10 years. He drinks alcohol rarely.
Family History: Both parents are alive and well. One sister has Down syndrome. Paternal grandfather has COPD, hypertension, and diabetes mellitus.
Review of Systems: Negative except for complaint of pain in the right lower quadrant.
Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.
Laboratory Data: Hemoglobin 14.6, hematocrit 43.6, and WBC 13,000. Sodium 138, potassium 3.8, chloride 105, C02 24, BUN 10, creatinine 0.9, and glucose 102. Urinalysis was negative.
Diagnostic Studies: Flat plate and upright films of the abdomen revealed a localized abnormal gas pattern in the right lower quadrant with no evidence of free air.
Impression: Appendicitis
Plan: The patient will be admitted, kept NPO, and an appendectomy will be performed by Dr. Rogers in the morning.
Discussion Questions: Identify one or two medical terms in this report. Deconstruct the components of specific medical terms to identify their meanings. In addition, please pay attention to the spelling and pronunciation of the words.
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