Download Team - University of Phoenix

Symptom Analysis and Organization of Data for Written Record
NRP/516 Version 2
University of Phoenix Material
Symptom Analysis and Organization of Data for Written Record
Scenario 1: Mrs. D., a new patient, comes to see you because of fatigue. She is a known
diabetic.
Each sentence or phrase of the history and physical examination is presented in random order.
First, identify which ones are essential pieces of information when writing a chart note. Then
organize the data into a standard format by labeling each item as listed below:
ID =
Identifying Statement
CC =
Chief Complaint
HPI =
History of Present Illness
PMH =
Past Medical History
MEDS =
Medications, Vitamins, Herbals
Allergies =
Allergies to foods, drugs, pollens
FH =
Family History
SH =
Social History
ROS =
Review of Systems
S=
Subjective Date
O=
Objective Data
A=
Assessment
P=
Plan
_____ The lungs are clear to percussion and auscultation.
_____ Mrs. D. was born near Rochester, completed high school, and worked as a sales clerk for
several years before marrying. She is 63-years old.
_____ She had pneumonia 3 times last year.
_____ She had systolic murmur grade II/VI.
_____ Scarlet fever at age 8.
_____ One son, age 40, alive and pre-diabetic.
_____ Four years ago, after gaining about 15 pounds to her present weight of 150, Mrs. D. first
noted fatigue, polyuria, and polydipsia.
_____ Father died age 65 of myocardial infarction.
_____ For several months, some dull occipital headaches.
_____ Range of joint motion is full.
_____ At home glucose 295.
_____ Fasting triglycerides 586.
_____ Pelvic and rectal examination is deferred until next visit.
_____ Full oral polio immunization.
_____ Last tetanus booster 8 years ago. No Pneumovax or shingles vaccine.
_____ Appendectomy, age 15.
_____ Mother died, age 63, of a cerebrovascular accident; mother had diabetes and
hypertension.
_____ The mortgage is paid on their small house, but savings are few.
_____ Mrs. D. is an obese, short, women.
1
Symptom Analysis and Organization of Data for Written Record
NRP/516 Version 2
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Mrs. D. is a 65-year-old, recently widowed, white women.
Per patient, she has had no serious illnesses, and her general health has been good.
Reflexes are 2+ and symmetrical, with down-going plantar responses.
Heberden’s nodes on both hands.
The hair is gray and of normal texture
The tongue is coated.
The trachea is midline; the thyroid is not felt.
Intermittent mild aching of knees and hips.
The abdomen is obese and non-tender, no organs or masses are felt due to obesity.
Mrs. D. has two children, both of whom are now married and live out of town.
After the diagnosis of diabetes, a weight reduction regimen was instituted but was
unsuccessful. She was started on metformin three and one-half years ago
She has not had serious accidents.
She presently takes 1.0 grams of metformin twice daily.
She comes to the clinic complaining of fatigue.
Menopause at age 45.
She communicates easily but become tearful when talking of her husband’s death.
Pulse 76, regular; blood pressure 140/85; respiration 16, weight 162 pounds.
Some redness and retraction of the gums.
Cervical and axillary nodes are not palpable.
Breasts are symmetrical without masses.
Since her husband died rather suddenly of an acute myocardial infarction; she has had
trouble adjusting to his death and has become increasingly fatigued.
Sclerae is clear, conjunctiva is pink and moist
Extraocular movements are intact; pupils are equa,l round, and react to light and
accommodation; the fundi show early signs of narrowing of vessels at the crossing.
One daughter, age 36. alive and well.
There is some edema, +2 bilaterally, and the dorsalis pedis and posterior tibial pulses are
+1.
Tempanic membrane is intact.
She has been sleeping poorly, awakening in the early morning hours. Up to void x3/night.
The nasal septum is deviated to the left, but the airway is clear.
Per patient, there are no present symptoms of diabetes.
Post pharynx rises with “ah”. Post pharynx with exudative pustules, post pharynx with
cobble stoning, etc.
2
Symptom Analysis and Organization of Data for Written Record
NRP/516 Version 2
1. Symptom Analysis
PQRST
OLDCARTS
[Previous Occurrence]
Precipitating factors
Onset
Quality
Location
Region or radiation
Duration
Severity
Characteristics
Temporal factors
Aggravating
Results of treatment
Relieving
Significant negatives
Treatment
[Severity]
2. What elements are involved in the coding process?
3
Symptom Analysis and Organization of Data for Written Record
NRP/516 Version 2
Scenario 2: Mrs. D’s Revisit
A short note on Mrs. D’s revisit has been randomized. Organize the data into the problemoriented format by labeling each item as listed below:
S=
O=
A=
P=
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Subjective
Objective
Assessment
Plan
Urine sugar today negative.
Is not tearful today.
We shall continue to support and accept grieving.
Has lost 5 pounds.
Diabetes better controlled.
Is taking metformin BID.
Sleep improved.
Polyuria and polydipsia have resolved.
Depression improving.
Continue diet and metformin.
Getting out with friends more.
Using the information provided above in the revisit, complete the symptom analysis in the table
below.
3. Symptom Analysis
PQRST
OLDCARTS
[Previous Occurrence]
Precipitating factors
Onset
Quality
Location
Region or radiation
Duration
Severity
Characteristics
Temporal factors
Aggravating
Results of treatment
Relieving
Significant negatives
Temporal
[Severity]
4. What elements are involved in the coding process?
4