While transcribing an OB/GYN history and physical examination, you hear, "HISTORY: "G2, P …" The dictating voice cuts out, obliterating the number dictated after "P." According to your employer's preferences, you leave a blank consisting of five underscores (P) to signify dictation that was either unintelligible or was completely missing. Under GYN HISTORY, the dictation is, "The patient had 2 uncomplicated vaginal deliveries in 2001 and 2005." How is the HDS to proceed?
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- Q: (1) The co-anchor for a local television station newscast comes to a clinic for a blood test. The phlebotomist recognizes her immediately. They have a pleasant conversation while the phlebotomist draws the specimen. Later that evening the phlebotomist says to her husband, ?Guess who I drew today?? She then proceeds to tell him the co-anchor?s name, adding, ?she is probably bipolar because I drew a lithium level on her.? (1) What mistake did the phlebotomist make? (2) What law was violated by her actions? (3) What legal action could result? -M.H. is an 80-year-old Caucasian female who is married and lives with her spouse. She presents to your office today with her spouse, feeling “coocoo, I just don’t feel right.” Currently she is taking rosuvastatin prescribed by her cardiologist for hyperlipidemia and a daily 325 mg aspirin. She drinks 3–6 hard liquor drinks a day, 3–4 times a week in the evening, and has a 65-year smoking habit, currently smoking two packs per day (ppd). She has no known allergies. Past surgical history includes hysterectomy for a benign fibroid. Family history of breast cancer in three sisters, Type 2 diabetes and CVA in one sister, cancer of unknown origin in one brother. All siblings and parents are deceased. Her husband reports that she is hard of hearing. He feels that it is due to cerumen build-up in her ears. She refuses to have the buildup removed. Her husband is also worried about her memory—states that she “just does not remember things like she used to. She keeps asking me the same questions…Mr. Anwari, age 73, is brought to the physician’s office by his daughter, Lucy, who is a licensed practical nurse (LPN). She states her concerns about her father: During the past 2 months he has been found wandering in the neighborhood because he forgets where he lives. Neighbors see him, note that he appears confused, and bring him home. Lucy is worried that her father is showing signs of early Alzheimer’s disease.1. Describe the physical changes that occur in the cortex of the brain.2. Describe the stages of Alzheimer’s disease.3. Describe the physiological and psychological changes that occur during Alzheimer’s dementia.4. What are the functions of the frontal lobe of the cerebral cortex?5. What parts of the limbic system may be affected in Alzheimer’s disease?6. What would be the concerns of the family when a person is diagnosed with this disease?
- According to your analysis of the case, what factors are contributing to the patient’s presenting signs and symptoms? Should she/he continue her/his current medication regimen? Why or why not? Which medications should be continued and which medications should be eliminated? What treatments or interventions do you anticipate being ordered for this client?Shirley Smith Age: 52Race: CaucasianGender: FemaleHeight: 68 inchesWeight: 153 lb. (69.4 kg) Occupation: Retired Marital Status: Widowed Religion: AgnosticAllergies: None knownAddress: Assisted Living facilityImmunizations: Up to date HistoryShirley's husband died unexpectedly 2 months ago, which is the time she enteredan assisted living facility. Shirley states she has become depressed from the lossof her husband and the inability to physically do activities she desires due to theCOPD.Shirley presents to the ER with difficulty breathing and shortness of breath atrest, and increased fatigue. The patient is currently on 2 Liters of oxygen nasalcanula at all times. Shirley smoked cigarettes for 32 years and just recently quit 2months ago when she was put on full-time oxygen.Past medical history: hysterectomy at the age of 48, Gastroesophageal refluxdisease (GERD), and Atrial Fibrillation. MedicationsPrednisone (HOLD) 20 mg oral DailyPantoprazole 40 mg oral DailyWarfarin 5 mg oral…Shirley Smith Age: 52Race: CaucasianGender: FemaleHeight: 68 inchesWeight: 153 lb. (69.4 kg) Occupation: Retired Marital Status: Widowed Religion: AgnosticAllergies: None knownAddress: Assisted Living facilityImmunizations: Up to date HistoryShirley's husband died unexpectedly 2 months ago, which is the time she enteredan assisted living facility. Shirley states she has become depressed from the lossof her husband and the inability to physically do activities she desires due to theCOPD.Shirley presents to the ER with difficulty breathing and shortness of breath atrest, and increased fatigue. The patient is currently on 2 Liters of oxygen nasalcanula at all times. Shirley smoked cigarettes for 32 years and just recently quit 2months ago when she was put on full-time oxygen.Past medical history: hysterectomy at the age of 48, Gastroesophageal refluxdisease (GERD), and Atrial Fibrillation. MedicationsPrednisone (HOLD) 20 mg oral DailyPantoprazole 40 mg oral DailyWarfarin 5 mg oral…
- Jerry Decker, a 90-year-old male, is admitted to Sunny Valley Residential Center. The H&P reports an admission diagnosis of vascular dementia with violent behavior. The two ICD-10-CM codes reported are:Name: William Shear Age: 18 Diagnoses: Autism (high functioning) and borderline personality disorder (has behavioural outbursts especially if nicotine craving is not alleviated)- nicotine dependence Interests: Sports, video games, hanging out with friends (enjoys someone older for guidance), outdoors Needs: education on diagnoses, support for employment, recreation & leisure support, support with anger & learning to relax Using the information above, please find resources or organizations that can support William with his diagnoses, his interests, and his needs. Please explain each choice (where you found it, why you chose it, how it will benefit the client).SITUATION: Mr Chong was brought into Emergency Department (ED) last night by ambulance after collapsing at home. The ED Registered Nurse reported that Mr Chong was alert and orientated to person, time and place on admission. He has global aphasia, left gaze preference, right homonymous hemianopia (field cut), right facial droop, dysarthria, and right hemiplegia. CT angiography showed a left Middle Cerebral Artery (MCA) occlusion (Fig 1). 12-lead ECG showed Atrial Fibrillation (Fig 2). BACKGROUND Mr Chong has a past medical history of Coronary Artery Disease, Coronary Artery Bypass Grafting, Atrial Fibrillation and previous TIA (Transient Ischaemic Attack) three month ago. Mr Chong is retired and independent with activities of daily living. He speaks simple English. Mr Chong lives with his wife and two sons. ASSESSMENT His last Glasgow Coma Scale (GCS) is between 13-14 (disorientated and occasionally confused to time and place) and other vital signs are within normal limits. His BGL:…
- SITUATION: Mr Chong was brought into Emergency Department (ED) last night by ambulance after collapsing at home. The ED Registered Nurse reported that Mr Chong was alert and orientated to person, time and place on admission. He has global aphasia, left gaze preference, right homonymous hemianopia (field cut), right facial droop, dysarthria, and right hemiplegia. CT angiography showed a left Middle Cerebral Artery (MCA) occlusion (Fig 1). 12-lead ECG showed Atrial Fibrillation (Fig 2). BACKGROUND Mr Chong has a past medical history of Coronary Artery Disease, Coronary Artery Bypass Grafting, Atrial Fibrillation and previous TIA (Transient Ischaemic Attack) three month ago. Mr Chong is retired and independent with activities of daily living. He speaks simple English. Mr Chong lives with his wife and two sons. ASSESSMENT His last Glasgow Coma Scale (GCS) is between 13-14 (disorientated and occasionally confused to time and place) and other vital signs are within normal limits. His BGL:…Given the following Doctor’s Orders, Interpret or Translate the underlined word(s) using the correct medical terms or abbreviations:Mary Brown [MB] is a healthy 36-year-old woman with complaints of persistent generalized fatigue. At her annual checkup, her vital signs: heart rate (HR), 118 beats/min; blood pressure (BP), 110/60 mm Hg; oral temperature, 37°C; and respiratory rate (RR), 26 breaths/min. Her skin, conjunctiva and nail beds are pale. Laboratory results: hematocrit (Hct), 27%; hemoglobin (Hb), 9 g/dL and hypochromatic red blood cells (RBCs) are present. What other history data would be helpful in determining the cause of this disorder?