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Medical Terminology
Medical Terminology
Medical Records Analysis
#1
Deer Summit Clinic
Department of Dermatology
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Johnson, S. H.
DATE: March 9, xxxx
S:
Pt is a 45 y/o professional accountant. He is divorced and lives alone. He
comes to the clinic today with an extensive rash over his forehead and ears. He
reports that the lesions have been present in some degree for the past three to
four months, but have become worse in the past few weeks. He has tried OTC
remedies, including various soaps, without relief. Pt is experiencing a great deal
of stress form the breakup of a five-year relationship with a woman he had
expected to marry and believes the stress contributes to his condition.
O:
Eyrthema with greasy, yellow scales, across the entire forehead from hairline to
eyebrows. External ears are similarly involved. There are patchy erythemateus
lesions with scaling along the hairline at the back of the neck. Erythematous
pupules are scattered across the face, and skin appears quite oily around the
nostrils.
A:
Seborheic dermatitis.
P:
Rx: hydrocortisone cream, 4%, 1 oz. tube.
Sig: apply to affected areas bid
Pt was counseled on avoiding stress and stress-relieving measures, since that
aggravates his condition. He was instructed to avoid soap on the area and to
use only an oatmeal cleansing bar on his face. He is to also avoid OTC
preparations. He is to RTC in four weeks if the condition is not greatly improved.
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Medical Terminology
Medical Records Analysis #1
Answer the following questions based on the progress note above:
1. What is the patient’s age and gender?
2. What is the patient’s CC?
3. Describe the patient’s rash. Where is it located?
4. In addition to the rash, name one other objective finding.
5. In your own words, what is the diagnosis and what is the treatment?
6. Locate the four spelling errors in the document. Write the correct spelling of the
terms.
7. List two medical abbreviations found in the progress note and define them.
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Medical Terminology
Medical Records Analysis #1 KEY
Answer the following questions based on the progress note above:
1. What is the patient’s age and gender?
45, M
2. What is the patient’s CC?
Rash
3. Describe the patient’s rash. Where is it located?
Yellow, greasy, scaly across entire forehead from hairline to eyebrows & on
external ears. Also, on hairline at back of neck & across face.
4. In addition to the rash, name other objective finding.
Skin appears oily around nostrils
5. In your own words, what is the diagnosis and what is the treatment?
Inflammation of the skin because of increased sebaceous gland secretions.
Hydrocortisone cream to the affected areas.
6. Locate the four spelling errors in the document. Write the correct spelling of the
terms.
Eyrthema = erythema
Erythemateus = erythematous
Pupules = _____
Seborheic = seborrheic
7. List two medical abbreviations found in the progress note and define them.
y/o = year old
OTC = over the counter
Pt = patient
bid = twice a day
RTC = return to clinic
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Medical Terminology
Medical Terminology
Medical Records Analysis
#2
Deer Summit Clinic
Department of Pediatrics
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Ashley K.
DATE: Nov. 8, xxxx
S:
Pt is a 9 y/o. She comes to the clinic today accompanied by her mother, who is
quite concerned about her daughter’s symptoms. Mother states that her
daughter has always been a healthy child, and has had no problems until
recently. She has been in the clinic here for check-ups and immunizations. She
reports that over the past few months she has become quite clumsy, falling
down, dropping things, etc. Pt admits to some muscle weakness and feeling
“trembly” in her legs. She says, “I’m tired.”
O:
Examination of the HEENT is WNL. T 98.2, P 66, R14, BP 100/72. Auscultation
of the precordial area reveals RRR, without murmurs. Lungs clear. Neurological
exam is generally WNL. Skeletal muscles in the extremities appear hypertrophic
and firm. Grip strength is somewhat , and biceps strength appears less than
expected. No contractures noted at this point.
A:
Possible muscular dystrophic disorder.
P:
Admit to Summit Medical Center for:
1) Muscle biopsy.
2) EMG.
3) 24-hour blood samples for CPK.
4) 24-hour urine collection for creatinine.
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Medical Terminology
Medical Records Analysis #2
Answer the following questions based on the progress note above:
1. What is the age and the gender of the patient?
2. Where was the patient seen?
3. Describe the findings from the physical examination.
4. What is the assessment? Is this an infectious disease?
5. List three tests that are to be performed.
6. List 4 medical abbreviations found in the progress note and define them.
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Medical Terminology
Medical Records Analysis #2 KEY
Answer the following questions based on the progress note above:
1. What is the age and the gender of the patient?
9, F
2. Where was the patient seen?
Deer Summit Clinic
3. Describe the findings from the physical examination.
HEENT are normal, regular heart sounds and rate, clear lungs, normal
neurological exam, leg and arm muscles appear to be increased in size from
normal, grip strength is increased, and biceps muscle strength is weak.
4. What is the assessment? Is this an infectious disease?
Possibly muscular dystrophy – not infectious
5. List 3 tests that are to be performed.
a. muscle biopsy
b. EMG
c. blood test
d. urine test
6. List 4 medical abbreviations found in the progress note and define them.
a. y/o = year old
b. pt = patient
c. HEENT = head, eyes, ears, neck, throat
d. WNL = within normal limits
a. T = temperature
b. P = pulse
c. R = respirations
d. BP = blood pressure
e. RRR = regular rate and rhythm
f.  = increased
g. EMG = electromyogram
h. CPK = creatine phosphokinase
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Medical Terminology
Medical Terminology
Medical Records Analysis
#3
Deer Summit Clinic
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Joel G.
DATE: August 12, xxxx
S:
40 y/o white M reports increasing night sweats, low back pain, headaches, persistent
cough, lack of appetite and general malaise. Denies polyuria, hematuria, and states he
believes his longstanding cystitis may be better this week. He states that he easily
becomes fatigued and often has difficulty sleeping. Patient states, “It is so hard to get up
in the morning, most days I just stay in bed.” He is unemployed and living with his
parents following his diagnosis of HIV infection in 1999. He continues to be followed by
Dr. J. Carter in Salt Lake City for treatment of his primary diagnosis and receives AZT;
he reports taking that medication as directed. Patient states that in the past three
months his CD4 count which has been decreasing, seems to have stabilized. The count
is still low, however, with an absolute value of 260. He acknowledges additional
diagnoses of chronic active hepatitis, chronic cystitis, oral candidiasis, and depression.
His depression is currently being treated with Triavil, and he reports taking that
medication as directed. He states that he has stopped smoking as of last month, and
does not consume ETOH. He is seen in the clinic today for routine follow-up.
O:
Pt is thin, pale, and appears somewhat fragile. Movements and speech are somewhat
slow. Vital signs: T 98, P 92, BP 142/88. Supraclavicular lymph nodes are enlarged and
shotty. Oral mucosa is slightly reddened, but appears otherwise normal. There is no
leukoplakia. Mild bilateral wheezing on expiration. Left side of abdomen is soft and
nontender; right side is mildly tender. No suprapubic tenderness. Liver margin is
palable approximately 2 cm below the costal margin; hepatomegaly is unchanged since
last exam. Back is slightly tender to palpation throughout the lumbar area. Remainder
of examination is unremarkable.
A:
1)
2)
3)
4)
5)
P:
1) Patient will continue AZT therapy and will continue to be followed by Dr. Smith.
2) D/C Triavil
3) Zoloft, 50 mg, 1 tab qam
4) Routine clinic labs
5) Social worker to discuss appropriate short- and long-term goals with patient and
explore aspects of depression.
Skills
HIV infection
Chronic hepatitis B.
Chronic depression, not responding well to current therapy.
Chronic cystitis.
Chronic oral candidiasis infection.
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Medical Terminology
Medical Records Analysis #3
Answer the following questions based on the progress note above:
1. What does “general malaise” mean?
2. Describe three findings from the physical examination.
3. What is leukoplakia?
4. What does the notation “D/C Triavil” mean?
5. What are the instructions for taking the Zoloft?
6. List 4 medical abbreviations found in the progress note and define them.
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Medical Terminology
Medical Records Analysis #3 KEY
Answer the following questions based on the progress note above:
1. What does “general malaise” mean?
Overall discomfort or uneasiness
2. Describe three findings from the physical examination.
Increased pulse and blood pressure, enlarged lymph nodes, redness of the lining
of the mouth, wheezing , right abdomen tender, tender back through lumbar
region
3. What is leukoplakia?
Formation of white spots or patches on the mucous membranes of the tongue or
cheek
4. What does the notation “D/C Triavil” mean?
Discontinue the drug Triavil
5. What are the instructions for taking the Zoloft?
Take one 50mg every morning
6. List 4 medical abbreviations found in the progress note and define them.
y/o = year old
M = male
ETOH = alcohol
Pt = patient
t = temperature
p = pulse
bp = blood pressure
cm = centimeter
HIV = human immunodeficiency virus
mg = milligram
tab = tablet
qam = every morning
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Medical Terminology
Medical Terminology
Medical Records Analysis
#4
Deer Summit Clinic
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Shonda B.
DATE: May 25, xxxx
S:
This 18 y/o F is seen in the office, c/o nausea and vomiting for the past six hours.
She is accompanied by her sister, who provides much of the history. Pt. reports
a severe headache, and states she feels like she has in the past when she was
on the verge of a coma. She was diagnosed with IDDM at the age of 10 and has
taken insulin ever since. She is on an 1800 cal. diet. She uses an Accu-Chek at
home and evaluates her glucose levels bid. She reports that her levels have
been around 60 to 70 for the past four days. Two days ago she had an episode
where she felt shaky, anxious, and confused. She had palpitations, was
sweating, and felt weak. She has not taken her insulin since that time.
O:
T 96, P 105, R 22, B/P 120-66. Skin is warm and dry. Xerosis of hands, arms
and perioral area. Odor of ketones is detected in the breath. Biochem results:
sodium 125, potassium 4.2, chloride 101, CO2 10, glucose 412.
A:
Diabetic ketoacidosis.
P:
10 units regular insulin stat.; check BS in 1h., then q4h; urine checks for sugar,
acetone, and volume q voiding; admit to Summit Medical Center.
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Medical Terminology
Medical Records Analysis #4
Answer the following questions based on the progress note above:
1. What brought this patient to the doctor’s office?
2. What is the patient’s prior diagnosis?
3. What kind of test did the patient have in the office? Was the patient’s blood
sugar checked?
4. What was the condition of the patient’s skin?
5. Was any medication prescribed? When is it to be give?
6. List two tests that are to be performed. When are they to be done?
7. Why is it necessary to hospitalize the patient?
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Medical Terminology
Medical Records Analysis #4 KEY
Answer the following questions based on the progress note above:
1. What brought this patient to the doctor’s office?
Patient has experienced nausea, vomiting, severe headache, and feels on the
verge of a coma
2. What is the patient’s prior diagnosis?
IDDM – Insulin dependent diabetes mellitus
3. What kind of test did the patient have in the office? Was the patient’s blood
sugar checked?
Biochemistry lab work. Yes, her blood sugar (glusocse) level is 412
4. What was the condition of the patient’s skin?
Her skin is warm and dry, and her hands, arms and the area around her mouth
are abnormally dry
5. Was any medication prescribed? When is it to be give?
Yes – insulin to be given immediately
6. List two tests that are to be performed. When are they to be done?
Check blood glucose levels in 1 hour and then every 4 hours after.
Urinanlysis for glucose (sugar), acetones, and total volume
7. Why is it necessary to hospitalize the patient?
__________
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Medical Terminology
Medical Terminology
Medical Records Analysis
#5
Deer Summit Clinic
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Bernice B.
DATE: January 11, xxxx
S:
Bernice B, a 69 y/o F pt of this clinic, was seen in the clinic, accompanied by her
sister, Mabel R. The sister states that she went to Bernice’s home to pick her up
and bring her to the clinic for a routine visit, related to Bernice’s previous diagnosis
of hypertension. She found Bernice in an agitated, confused state. The sister was
somewhat alarmed, since this represents a dramatic change from Bernice’s
condition of just two days ago. She decided to go ahead and bring Bernice in for her
regular appointment and an evaluation. She does not know of any illnesses or other
diagnoses, aside from those we have been following Bernice for. She is not aware
of any accidents, falls, or injuries. Mabel states that she believes Bernice has been
taking her medication as prescribed. The patient is unable to provide adequate
history or description of current problems due to aphasia and mental confusion.
O:
T 98.8, P 86, R 20, BP 150/92.
Previous diagnoses: hypertension, mild peripheral vascular disease, status one year
post-mastectomy secondary to diagnosis of breast malignancy.
Neurological exam reveals several deficiencies in functioning; otherwise,
examination is unchanged from clinic visit of three weeks ago. Patient is aphasic
and appears anxious. She is somewhat able to answer “yes” or “no” to questions by
moving her head, but this is not a consistent ability. She is mentally confused.
There is diminished sensation of the R arm, thorax, and leg. There is a steady
stream of tears from the R eye and ptosis of the R lid. Vision is blurred, but actual
visual status is difficult to ascertain because of patient’s current mental status.
Patient is ataxic, with some hemiparesis on the R side; motor reflexes are intact on
the left and slightly exaggerated on the R. Preliminary laboratory studies of blood
and urine are unremarkable.
A:
R/O cerebral lesion of unknown etiology.
R/O endocrine disorder
P:
1. Admit to Summit Medical Center.
2. Obtain brain scan, EEG, and skull x-rays ASAP.
3. Laboratory studies for liver, renal, and thyroid function.
4. Neurological consult with Dr. Andersen.
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Medical Terminology
Medical Records Analysis #5
Answer the following questions based on the progress note above:
1. What is the patient’s mental status?
2. Briefly describe the findings from the physical examination.
3. What is the analysis? Is this an infectious disease?
4. Was any medication prescribed?
5. What radiologic studies will be done? Will further laboratory studies be done?
6. Why will the patient see another physician?
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Medical Terminology
Medical Records Analysis #5
KEY
Answer the following questions based on the progress note above:
1. What is the patient’s mental status?
Agitated, confused, unable to communicate
2. Briefly describe the findings from the physical examination.
High blood pressure, mental confusion, diminished sensation in the right arm, thorax,
and leg. Tears and dropping of the right eye with blurred vision. Lacks muscular
coordination, some paralysis on the right side with slightly exaggerated reflexes on
the right side. Normal blood and urine tests.
3. What is the analysis? Is this an infectious disease?
Possibly an injury to the brain or an endocrine disorder – neither are infectious
4. Was any medication prescribed?
No
5. What radiologic studies will be done? Will further laboratory studies be done?
Radiology = Brain scan, EEG, skull x-rays
Laboratory = liver, renal, thyroid function
6. Why will the patient see another physician?
Yes – Dr. Andersen, Neurologist
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Medical Terminology
Medical Terminology
Medical Records Analysis
#6
Summit Medical Center
Department of ENT
2394 Highland Dr., Park City, UT 84111
(801) 555-8243
Physician’s Procedure Notes
PATIENT: Maria G.
DATE: June 5, xxxx
DATE OF OPERATION: June 5, xxxx
PREOPERATIVE DIAGNOSIS: Chronic bilateral otitis media with effusion
POSTOPERATIVE DIAGNOSIS: Chronic bilateral otitis media with effusion
OPERATION PERFORMED: Bilateral myringotomy with tubes
SURGEON: L. L. Ball, MD
ANESTHESIOLGOIST: M. Modamusi, MD
Procedure and Findings: The pt was brought to the surgical suite following the usual
preoperative preparation. Following intubation, general anesthesia was induced and
the ears were prepped and draped for microscopic myringotomy. After debridement
and removal of cerumen and debris from the R ear, the TM was examined and found to
be dull and immoblile. A myringotomy was carried out in the R ear. The inferior anterior
quadrant circumference was incised and mucoid material was aspirated. A Shepard
tube was positioned without incident and cotton dressing applied. The TM of the L ear
was found to be similarly dull and immobile, and an inferior anterior myringotomy was
performed. Mucoid material was aspirated, and a Shepard tube placed. A sterile cotton
dressing was applied to the ear canal. No adenoiditis or adenoid hypertrophy was
noted. The pt tolerated the procedure well and was extubated without complications.
She was sent to the recovery room in satisfactory postoperative condition.
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Medical Terminology
Medical Records Analysis #6
Answer the following questions based on the progress note above:
1. What was the name of the procedure?
2. Where was the procedure performed?
3. Why was the procedure performed? Is an infectious disease involved?
4. What two procedures were performed immediately following intubation?
5. What two things were removed from the right ear before it was examined?
6. What was the condition of the right tympanic membrane prior to incision?
7. What was the condition of the left tympanic membrane prior to incision?
8. Where was the tube placed in the left ear? In the right ear?
9. What kind of dressings were used?
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Medical Terminology
Medical Records Analysis #6
KEY
Answer the following questions based on the progress note above:
1. What was the name of the procedure?
Bilateral myringotomy with tubes
2. Where was the procedure performed?
Summit Medical Center – surgical suite
3. Why was the procedure performed? Is an infectious disease involved?
Patient was having chronic bilateral ear infections – Not infectious
4. What two procedures were performed immediately following intubation?
General anesthesia was given and the ears were prepped and draped
5. What two things were removed from the right ear before it was examined?
Dead or damaged tissue and ear wax
6. What was the condition of the right tympanic membrane prior to incision?
It was found to be “dull and immobile”
7. What was the condition of the left tympanic membrane prior to incision?
The same as the right, dull and immobile
8. Where was the tube placed in the left ear? In the right ear?
Inferior and anterior in both ears
9. What kind of dressings were used?
Sterile cotton
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Medical Terminology
Medical Terminology
Medical Records Analysis
#7
Deer Summit Clinic
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Tyson S.
DATE: January 15, xxxx
S:
This is a 24 y/o M, in no obvious respiratory distress. Patient c/o sudden onset of
chest pain, beginning two days ago. This is a vague, generalized discomfort that
is aggravated by breathing and coughing. He states that he often becomes
fatigued and must stop to rest when doing even simple activities. He reports no
other symptoms, and states he has no chronic illnesses and has not been
involved in any accidents recently. He has a history of childhood asthma, but no
attacks in several years. He is a medical office worker, and has no known
exposure to toxic substances. He was ill about a month ago with pneumonia,
which was treated with antibiotics. He did not keep his follow-up appointment to
recheck the pneumonia following therapy.
O:
VS: T 101.8 F, P 72, R 28 and shallow, B/P 124/66
Breath sounds are diminished; no wheezes, rales, or crackles are noted.
Coughing is minimal and nonproductive. A few fine crackles are auscultated
over the right lateral chest. No cyanosis; motion of the chest wall is symmetrical.
No other remarkable findings.
A:
Pleurisy
P:
1. Obtain CXR to r/o fluid accumulation in the pleural space.
2. Oral penicillin G, 400,000 U, q6h, for 10 days.
3. Ibuprofen, 800 mg, q4h.
4. Pt to phone the clinic tomorrow for results of CXR and follow-up instructions.
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Medical Terminology
Medical Records Analysis #7
Answer the following questions based on the progress note above:
1. What is the patient’s occupation? Might this be a factor in the illness?
2. What are the two findings with regard to the patient’s health history?
3. Briefly describe the findings from the physical examination?
4. What is the analysis? Is this a chronic illness?
5. Which medications were prescribed? How often will the patient take the
medications and for how long?
6. What radiologic studies will be done?
7. Will further laboratory studies be done? If so, what are they?
8. What additional action is the patient to take?
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Medical Terminology
Medical Records Analysis #7
KEY
Answer the following questions based on the progress note above:
1. What is the patient’s occupation? Might this be a factor in the illness, why?
Medical office worker. He is always around sick people – chronic exposure;
could also be exposed to toxic substances as part of job
2. What are the two findings with regard to the patient’s health history?
Childhood asthma
Pneumonia treated with antibiotics approximately one month prior
3. Briefly describe the findings from the physical examination?
High temperature, rapid, diminished, and shallow breathing, crackling of the
lungs
4. What is the analysis? Is this a chronic illness?
Pleurisy – inflammation of the membranes around the lungs. It can be chronic.
5. Which medications were prescribed? How often will the patient take the
medications and for how long?
Penicillin G, 400,000 units every 6 hours for 10 days
Ibuprofen 800 mgs every 4 hours
6. What radiologic studies will be done?
Chest xray
7. Will further laboratory studies be done? If so, what are they?
No
8. What additional action is the patient to take?
Call the clinic the next day for xray results and further instructions
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Medical Terminology
Medical Records Analysis
#8
Deer Summit Clinic
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Office Chart Note
PATIENT: Robert R.
DATE: October 31, xxxx
S:
Patient states he is 65 y/o and is not aware of any previous heart problems. He
is the CFO of a large organization and experiences considerable stress related to
his job. He reports recent episodes of angina, beginning one week ago.
O:
The pt is M Caucasian who appears his stated age. He has been a pt here for
several years and has had no previous history of heart disease. He was last
seen approximately two years ago for a complete physical exam. We did a
resting ECG at that time that was interpreted as normal. When he reported the
angina last week, we did a complete examination and there was no evidence of
cardiomegaly, no murmurs, and no extra heart sounds. He did, however, have a
mild tachycardia. The remainder of the ROS was unremarkable. An ECG
revealed sinus tachycardia and a CXR showed very mild L ventricular
hypertrophy. Echocardiography reports indicated that there was no valvular
dysfunction, and ejection fraction was calculated at 58%. The pt was referred for
a cardiac catheterization procedure to gain additional information. Today’s report
of the cardiac cath shows a 70 percent stenosis of the L anterior descending
coronary artery, immediately after the first septal branch. The remainder of that
artery and the other coronary arteries are WNL. Ejection fraction was reported
as 58%.
A:
Angina due to coronary artery stenosis.
P:
We discussed the results of the cardiac cath and plans for the management of
this illness. He will be managed medically for the present. We will perform a
thallium stress test to determine reaction to exercise and the extent of the anginal
symptoms. If there is a marked reversible ischemia, we will consider angioplasty
of the L anterior descending coronary artery.
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Medical Terminology
Medical Records Analysis #8
Answer the following questions based on the progress note above:
1. What is the patient’s diagnosis?
2. What type of specialist is best suited to manage this patient’s condition?
3. What type of the problem did the patient report a week ago?
4. Describe three findings related to the heart from the physical examination of one
week ago.
5. What type of tests were performed after the physical exam but before the cardiac
catheterization?
6. What were the results of those tests?
7. What is a cardiac catheterization, and why was it performed on this patient?
8. What did the cardiac catheterization reveal?
9. What additional test will this patient have? What may be considered based on
the test results?
10. What does “managed medically” mean?
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Medical Terminology
Medical Records Analysis #8 KEY
Answer the following questions based on the progress note above:
1. What is the patient’s diagnosis?
Pain due to narrowing of the coronary arteries
2. What type of specialist is best suited to manage this patient’s condition?
Cardiologist
3. What type of the problem did the patient report a week ago?
Angina - pain
4. Describe three findings related to the heart from the physical examination of one
week ago.
No enlarged heart, no heart murmurs or extra heart sounds
Mild rapid heart rate
5. What type of tests were performed after the physical exam but before the cardiac
catheterization?
Echocardiogram, chest xray
6. What were the results of those tests?
Very mild left ventricular enlargement
No abnormal valve function, ejection fraction at 58%
7. What is a cardiac catheterization, and why was it performed on this patient?
The passage of a catheter into the heart to look for blockages of the coronary
arteries
8. What did the cardiac catheterization reveal?
70% blockage of the left anterior descending coronary artery
9. What additional test will this patient have? What may be considered based on
the test results?
Thallium stress test
May consider angioplasty to open the artery
10. What does “managed medically” mean?
Treated with medication
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Medical Terminology
Medical Terminology
Medical Records Analysis
#9
Deer Summit Clinic
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Edgar Z.
DATE: September 20, xxxx
S:
Pt states that he is 35 y/o carpenter. He reports that yesterday afternoon, while
at work, he lifted a 75-lb. bag of nails and felt a sharp pain in his abdomen, near
the navel. The pain eventually lessened, after he rested, but never completely
went away, and he returned to work. The pain became worse throughout the day
and continued during the night. The pt states that his father recently died of
stomach CA and he is concerned that he might have the same illness.
O:
VS WNL. Pt appears to be in distress with moderate to severe abdominal pain.
Abdomen is soft, with generalized tenderness upon palpation. Tenderness is
most pronounced in the umbilical region and muscle spasms are noted in that
area. There is bulging around the umbilicus.
A:
Incarcerated umbilical hernia.
P:
Admit to Summit Medical Center stat. for herniorrhaphy. Pt to remain NPO.
Request surgical consult from Dr. Green.
Skills
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Medical Terminology
Medical Records Analysis #9
Answer the following questions based on the progress note above:
1. What was the nature of the patient’s complaint?
2. Where was the patient seen?
3. Describe four findings from the physical examination.
4. What was the analysis? Is this an infectious disease?
5. Was any medication prescribed?
6. Are any tests to be performed?
7. What type of procedure will the patient have?
8. Can the patient have dinner?
Skills
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Medical Terminology
Medical Records Analysis #9 KEY
Answer the following questions based on the progress note above:
1. What was the nature of the patient’s complaint?
Sharp pain in abdomen after lifting heavy object which became worse throughout
the day
2. Where was the patient seen?
Clinic
3. Describe four findings from the physical examination.
Vital signs are normal, abdominal pain, soft abdomen with generalized
tenderness specifically around the belly button, muscle spasms and bulging
around the belly button
4. What was the analysis? Is this an infectious disease?
Constricted umbilical hernia – Not infectious
5. Was any medication prescribed?
No
6. Are any tests to be performed?
No
7. What type of procedure will the patient have?
Surgical procedure to repair the hernia
8. Can the patient have dinner?
No
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Medical Terminology
Medical Terminology
Medical Records Analysis
#10
Deer Summit Clinic
1597 S. Parkview Dr, Park City, UT 84111
(801) 555-7455
Physician’s Progress Notes
PATIENT: Kaylee A.
DATE: December 6, xxxx
S:
20 y/o F states that she has been performing monthly beast self-exams, as she
was previously instructed in this office. Yesterday, as she was examining her L
breast, she noticed a lump in the lower, lateral aspect of the L breast. She states
that the area of the lump is slightly uncomfortable in a vague sort of way. She
reports that she is not sexually active and she is not using any type of
contraception.
O:
T 98.7, P 76, R 15, BP 124/76.
This pt was seen in the office approximately six months ago for her yearly
physical exam. No abnormalities were found, and her health was judged to be
very good at that time. In particular, there were no palpable masses in her
breasts and no external abnormalities of the breasts or nipples. We discussed
breast self-examination and several other health-promoting measures
appropriate for a young woman. We did a baseline mammogram at that time,
and the mammography report showed normal breasts. Today’s examination
reveals a firm, non-movable 2.5 cm nodule in the five o’clock position, in the L
lateral aspect of the L breast. There is a slight peau d’orange appearance of the
skin over the nodule, but no edema, no lesions, and no erythema. Axillary lymph
nodes are not palpably enlarged. R breast appears normal. ROS: findings
unremarkable.
A:
1. L breast mass.
2. R/O carcinoma of the breast.
P:
Mammogram today, with evaluation to be delivered to my office ASAP. Pt to
RTC tomorrow. Will make further plans based on mammography findings.
Skills
Page 28
Utah State Office of Education
Draft Copy
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Medical Terminology
Medical Records Analysis #10
Answer the following questions based on the progress note above:
1. Where was the patient seen? Why did she see the doctor?
2. Describe the findings from the physical examination today.
3. What is the analysis?
4. Was any medication prescribed? What type of test will the patient have?
5. Why is it important that the patient have the test soon?
Skills
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Medical Terminology
Medical Records Analysis #10
KEY
Answer the following questions based on the progress note above:
1. Where was the patient seen? Why did she see the doctor?
Clinic
She recently noticed a lump in her left breast
2. Describe the findings from the physical examination today.
Firm, non-movable nodule in the left breast, slight dimpling of the skin over the
nodule, no swelling, no lesion, no discoloration of the skin, no enlarged lymph
nodes in the armpit, right breast normal. Other systems are normal.
3. What is the analysis?
Mass in the left breast
4. Was any medication prescribed? What type of test will the patient have?
No medications
Mammogram of the breasts
5. Why is it important that the patient have the test soon?
The earlier the treatment, the better
Skills
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