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week 1

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 HISTORYHistory 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: NoneAllergies: No known drug allergiesSocial 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.

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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: AppendicitisPlan: 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.OUTPATIENT OFFICE ENCOUNTER 

Darryl McFadden is a 6-year-old male who complains of nasal blockage, postnasal drip, and cough, especially at night. His history reveals that he is exposed to a cat and also to dust and other factors in his household, which is located in a rural wooded area on an unpaved road. His symptoms are perennial but mainly from March through October.

 

DISCUSSION QUESTIONS: 

1. Reviewing the surgical history, provide the following in your post.

 

A. 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 spellingand pronunciation of the words.

 

B. Define the abbreviations found in the surgical report. How did you find the meaning of these abbreviations?

 

C. Using what you’ve learned about word parts, describe the types of surgeries listed in the patient’s past surgical history.

 

2. Reviewing the outpatient encounter of Darryl McFadden, accomplish the following and report in your findings and comments in your post.

 

A. Go to Research a Disease or Condition in the ADAM multimedia encyclopedia. Read all the information under allergies and look at the six images, the photo, and the video on allergies. After studying the material, summarize or paraphrase any information that you use in response to the

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discussion question this week. Be sure and cite your source appropriately. Do not copy and paste information. 

B. If Darryl McFadden was your child, what questions would you ask the doctor on the first office visit?

 

3. General questions:

 

A. Define in your own words the four types of word parts.

 

B. Identify each of the major body planes related to where they cross the body.

week 2

MUSCULOSKELETAL SYSTEM AND PATIENT ENCOUNTERS (GRADED)Class, in this thread we will be looking at musculoskeletal system terminology and related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in TerminalCourse Objective (TCO) 3. You must address all of the questions located after the example of dischargesummary and patient encounter of Carol Champion.

Discharge SummaryAdmission Diagnosis: Multiple compression fractures of T12, L1, L2, and L4Discharge Diagnosis: Same as above, non-acute fracturesHistory of Present Illness: This is a 70-year-old African-American female with a long history of multiple fractures dating back to 1992. She has a history of significant osteoporosis diagnosed in 1998. The patient also has a history of osteoarthritis and had a right total hip replacement in 2000. Two days prior to admission, the patient missed the final step coming down the stairs in her home. She caught hold of the railing but twisted as she did so and developed some back pain. This became progressively worse over the next 2 days to the point where she was having difficulty ambulating and she went to the Emergency Room.On evaluation in the ER, it was noted that she had compression fractures of the T12, L1, L2, L3, and L4 vertebrae. However, these could not be ruled out as new or old fractures due to lack of previous X-rays in this area. The patient was admitted for further evaluation.

Past Medical History: The patient is retired and lives in an independent living apartment in the Pine Valley retirement community. She does not smoke and has no alcohol intake. She has osteoporosis and osteoarthritis. Also of note is that approximately 10 days prior to admission, the patient had sustained a distal radius fracture of her left forearm for which she was treated with a splint by an orthopedist.Physical Examination: This is a well-developed, well-nourished elderly female in no acute distress. She had moderate discomfort on movement. Her HEENT exam was essentially normal. Her lungs were clear. Heart had a regular rate and rhythm. Abdomen was soft and nontender. Her rectal area

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showed good tone. Her back showed moderate tenderness to palpation in the upper lumbar and lower thoracic area. Neurologically, she was completely normal with cranial nerves being intact. Motor was 5/5 in all extremities except for the left extremity, which was not examined secondary to the arm being in a splint. She had deep tendon reflexes 2+ and equal. Her sensory exam was normal.Hospital Course: The patient was admitted and on the day following admission, she had a bone scan that revealed moderate degenerative joint disease of the T&L (thoracic and lumbar) spine with no evidence of acute compression fractures. The patient was placed on bed rest and was started with physical therapy and ambulation with which she has steadily progressed with decreasing pain and tenderness. The patient is now ambulating using a walker with a platform for her wrist splint.Social Services and Physical Therapy were consulted. She is ambulating well with her walker and it is felt she will do well staying with members of her family over the next 10 to 14 days, after which time she will be able to go back to living in her apartment.

The patient will follow up with the Orthopedic Clinic in 10 to 14 days. She will follow up with her private physician for the wrist fracture upon discharge.

Discharge Medications: Tylenol #3, one or two p.o. q 4-6 h. p.r.n.; Fosamax 5 mg daily, and she will continue with her Calcium t.i.d. 

OUTPATIENT OFFICE ENCOUNTER 

DISCUSSION QUESTIONS: 

week 3

CARDIOVASCULAR, LYMPHATIC, AND RESPIRATORY SYSTEMS CASE STUDIES (GRADED)Case Study 

Her risk factors are negative for hypertension or diabetes mellitus. She does admit to tobacco use, about one pack per day over the past 5 years, down from two packs a day over the preceding 20 years.

Family History: Her family history is negative for coronary artery disease.Allergies: NoneMedications: Medications include Lanoxin 0.125 mg daily, Slow-K 8 mEq t.i.d., and Lasix 40 mg a day.Operative History: She gives a history of cholecystectomy 5 years ago. Carcinoma of the colon was discovered and treated 10 years ago. 

OUTPATIENT OFFICE ENCOUNTER 

week 4

DIGESTIVE AND URINARY SYSTEMS CASE STUDIES (GRADED) 

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Class, in this thread we will be looking at digestive and urinary systems and their related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in TerminalCourse Objective (TCO) 5. You must address all of the questions located after the example of case study and patient encounter of Sarah Eubanks.

Operative ReportPreoperative Diagnosis: Acute cholecystitisPostoperative Diagnosis: Acute cholecystitis with partially gangrenous gallbladderOperation: Laparoscopic converted to open cholecystectomyAnesthesia: GeneralEstimated Blood Loss: 150 ccUrine Output: 100 ccIntravenous Fluids: 2500 cc of lactated Ringer’sComplications: NoneFindings: A partially gangrenous but mostly inflamed gallbladder with up to 1 cm thick gallbladder wall and multiple (greater than 50–100) small stones, each measuring approximately 2–4 mmDescription of Procedure: 

OUTPATIENT OFFICE ENCOUNTER 

week 6

INTEGUMENTARY AND ENDOCRINE SYSTEM CASE STUDIES (GRADED).

OPERATIVE AND PATHOLOGY CASE STUDY 

 

Pathology Report 

OUTPATIENT OFFICE ENCOUNTER 

DISCUSSION QUESTIONS: 

week 5

NERVOUS AND SPECIAL SENSES SYSTEMS CASE STUDIES (GRADED) 

OUTPATIENT OFFICE ENCOUNTER 

DISCUSSION QUESTIONS: 

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3. General questions:

A. Define the parts of the brain.

B. Name and define the cranial nerves I-XII.

week 7

REPRODUCTIVE SYSTEMS CASE STUDIES (GRADED) 

OPERATIVE CASE STUDYPreoperative Diagnosis: (1) Pregnancy, uterine, nondelivered at 40+3 weeks estimated gestational age, (2) arrest of dilationSurgeon: Randy Chornack, M.D.Anesthetist: Dr. AndrosiniAnesthesia: Continuous lumbar epiduralatient was delivered of a liveborn female infant with Apgar scores of 9 and 9 and weight of 3,422 g.

econium below the cord.

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