Axia 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. 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.

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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 46 year old male who is here for a refill of Imuran. He is taking it at a dose of 100 mg per day. Hes status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. He had an episode three weeks ago that brought him into the emergency room. He was experiencing sudden onset of abdominal pain and vomiting. He states that the inciting factor of this incident was from eating too many grapes the day before. He has experienced similar symptoms of obstruction when eating oranges or other high residue fruits in the past. Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests. At that time he was taking a lot of Tylenol for migraine type headaches. With the recommendation of the doctor he stopped the lmuran for one month and reduced his dose of Tylenol. since all this his liver enzymes have normalizes and he has restarted the lmuran with no problems. He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past. It at one time occurred once a week, but has now increased to twice a week. He takes over the counter medicines such as tums and H2 blockers as needed. Past Medical History He had a colonoscopy performed in August of 2003, by Dr. S. An anastomotic stricture was found at the terminal ileum/cecum junction. Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation. No active Crohn's disease was found during the colonoscopy. Crohn's disease, vitamin B12 deficiency. No known allergies to medications. He is currently taking Imuran, Nascobal, Vicodin p.r.n. Physical Examination Pleasant male in no acute distress. Well-nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length. Nontender to palpation. No erythema or red streaking. No edema. LYMPH: No epitrochlear or axillary lymph node enlargement or tenderness on the right side. Diagnostic/Lab Results Labs from June 8th and July 19th have been reviewed. Liver function tests normal with AST 14 and ALT 44. WBCs were slightly low at 4.8. Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04. These results were reviewed by Dr. S and lab results letter sent. Impression/Discussion 1. Crohn's disease, status post terminal ileum resection, on Imuran. Intermittent symptoms of bowel obstruction. Last episode was three weeks ago. 2. History of non-specific hepatitis while taking high doses of Tylenol. Now resolved. 2. Increased frequency of reflux symptoms. 3. Superficial thrombophlebitis, resolving. 4. Slightly low H&H. Two Questions for prospective hires

References http://www.mtsamples.com/site/pages/sample.asp?type=24-Gastroenterology&sample=221GI%20Consultation%20-%203

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Chapter 4 Medical Record History of Present Illness The patient is a 45-year-old male transferred to Maury Regional Hospital on 10/12/2011 from Crockett Hospital after an admission with acute ischemic CVA and DKA. The patient had a very complicated medical history, including respiratory failure, on prolonged mechanical ventilation. He underwent tracheostomy placement on 10/09/2011 and shortly thereafter was weaned from mechanical ventilation. He was also diagnosed with hospital-acquired pneumonia, multiorganism, and pulmonary embolism by CTPA. He currently is on heparin drip, while started on Coumadin. He also has end-stage renal disease and is on hemodialysis. Past Medical History In addition to the above, the patient was found to have some type of intracardiac shunt per echocardiogram, not otherwise defined, atherosclerosis of the internal carotid arteries, positive lupus anticoagulants and long-standing history of diabetes mellitus. There is a history of tobacco and alcohol abuse in the patient. The patient is currently taken these medications: Sliding scale insulin, Reglan, Lantus insulin, diltiazem, Timentin, heparin drip, Coumadin, Bactrim, Pepcid and iron sulfate. There are no known allergies. Physical Examination VITAL SIGNS: Temperature is 98.6 degrees; respiratory rate is 21 to 25, somewhat irregular; pulse is 102; blood pressure is 122/80 and pulse oximetry is 97% on 50% cuffless tracheostomy. HEENT: Unable to visualize posterior pharynx secondary to the patients resistance to mouth opening. The patient does have some natural dentition anteriorly. No coating of the tongue is appreciated. The patient has an eschar on the left upper lip, presumably secondary to ET tube. Conjunctivae are clear. Gaze is conjugate. The patient has a size 8 Portex cuffless tracheostomy tube in the midline. CHEST: The patient has a few crackles at the right base, few anterior coarse rhonchi. No wheeze or stridor with the tracheostomy tube, patent. With finger occlusion of the cuffless #8 Portex, the patient does have stridor and increased respiratory rate. Unable to adequately percuss the chest. CARDIOVASCULAR: The patient has regular rate and rhythm. No murmur or gallop is appreciated. No heaves or thrills. ABDOMEN: Soft and obese. The patient has G-tube in position and normoactive bowel sounds. No guarding. EXTREMITIES: He has decreased pulse in lower extremities bilaterally. No discrepancy in calf size is appreciated. No clubbing, cyanosis or edema. NEUROLOGIC: The patient does withdraw, on the left side, grimaces to pain. He is not cooperative with exam at this time. Diagnostic/Lab Results BUN 16 and creatinine 3.3 on 10/09/2011 with venous CO2 of 24, calcium 9.1, white count 9200, hemoglobin 9.2 and platelets 515,000. Chest x-ray is not available for review. Impression/Discussion The patient is a 45-year-old male, status post respiratory failure, prolonged mechanical ventilation, necessitating tracheostomy tube placement. He has had multiple complications including pulmonary embolism, for which he is now anticoagulated with heparin and reportedly intracardiac shunt, which would help explain his Aa gradient. He also reported he had a right-sided cavitary lesion and had negative AFB on bronchoalveolar lavage. Two Questions for prospective hires

References http://sites.google.com/site/medicaltranscriptionsamples/pulmonary-medical-transcriptionconsultation-sample-report

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Chapter 5 Medical Record History of Present Illness The patient is a forty eight year old female who has a long history of palpitations and typical chest pain. She underwent an echocardiogram in past, which showed mitral valve prolapsed. She explains her chest pain episodes as tingling and burning in nature. They are not related with exertion. They would last for 5 minutes and are not related with breathing shortness and it happens once every week. The patient says that her history of palpitations have improved on her verapamil and Tenormin. The patient denies any history of MI. Past Medical History A typical chest pain, Mitral valve prolapsed and palpitations. Surgical History: Bladder suspension, Appendectomy, Hysterectomy. She is currently on Medications: Verapamil 120 mg per day, Atenolol 50mg per day, Celexa 40 mg per day, one baby aspirin per day. There is a history of Tobacco Abuse A Family history of Coronary artery disease Physical Examination Heart: Regular rhythm, S1, S2 diminished. Systolic murmur in right sterna border. Lymphatics: Post Amputation, Negative Abdomen: Non-distended, Non-tender and Soft. There is no rebound, masses, guarding, ascites, hepatosplenomegaly, ascites, and hernias. Genitalia: Normal Rectal : Positive stool Chest: No rales, wheezes, rhonchi and Percussion dullness. She is not suffering from acute distress. Respiratory exams are clear for auscultation and neck veins arent distended. Cardiac exam reveals regular with systolic murmur and S1 and S2 are diminished. Soft and non-tender abdomen with palpation. GU exam does not reveal costovertebral tenderness and neurological examination is not-focal. Diagnostic/Lab Results Electrocardiogram: Sinus rhythm devoid of clear abnormalities in ST segment. Impression/Discussion Chest pain with irregular features and is not related with exertion and radiation is present all over her body and there is no strong explanation for this. Though it represents arrhythmia, non-cardiac or cardiac problems will be clear. Mitral Valve prolapse: There is no clear evidence and it has been previously documented. There wasnt any murmur with this examination. The patient has symptoms related to palpitations, preserved exercise tolerance and irregular chest pain and there is no clear explanation for chest pain. Apart from that, basic metabolic reaction like lipid, C-reactive proteins and BMP has been checked. I have asked her to follow up after 6 weeks. The patient will require gastro copy and colonoscopy for viewing his cardiopulmonary and amputation status. He will require twenty four hour admit on careful observation and IV fluids. Two Questions for prospective hires

References http://www.themtassist.com/blog/sample-medical-transcription-reports/

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