Hum/111 Week 1

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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.
History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and
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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.
OUTPATIENT OFFICE ENCOUNTER Darryl McFadden is a 6-year-old male
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