week 1
Patient Documentation Analysis (graded)
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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.
SURGICAL HISTORY
History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and vomiting. The initial onset of the pain was about 48 hours prior to presentation. The pain was progressive in nature and began radiating to the back. Late yesterday, the patient drank some Alka-Seltzer and went to bed. He was awakened during the night by the pain and began vomiting. The patient states the pain is constant and has localized to the right lower quadrant. His last bowel movement yesterday afternoon was normal. He does have a history of irritable bowel syndrome; however, he states that this pain is different than the pain he has had in the past.
Past Medical History: Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable.
Past Surgical History: Tonsillectomy and adenoidectomy in early childhood; umbilical hernia repair at age 4.
Medications: None
Allergies: No known drug allergies
Social History: The patient is employed as a computer programmer. He is married and has no children. He has smoked a half a pack of cigarettes daily for the last 10 years. He drinks alcohol rarely.
Family History: Both parents are alive and well. One sister has Down syndrome. Paternal grandfather has COPD, hypertension, and diabetes mellitus.
Review of Systems: Negative except for complaint of pain in the right lower quadrant.
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 o C (101.4 o F). 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 who complains of nasal blockage, postnasal drip, and cough, especially at night. His history reveals that he is exposed to a cat and also to dust and other factors in his household, which is located in a rural wooded area on an unpaved road. His symptoms are perennial but mainly from March through October.
DISCUSSION QUESTIONS:
1. Reviewing the surgical history, provide the following in your post.
A. 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 spellingand pronunciation of the words.
B. Define the abbreviations found in the surgical report. How did you find the meaning of these abbreviations?
C. Using what you’ve learned about word parts, describe the types of surgeries listed in the patient’s past surgical history.
2. Reviewing the outpatient encounter of Darryl McFadden, accomplish the following and report in your findings and comments in your post.
A. Go to Research a Disease or Condition in the ADAM multimedia encyclopedia. Read all the information under allergies and look at the six images, the photo, and the video on allergies. After studying the material, summarize or paraphrase any information that you use in response to the discussion question this week. Be sure and cite your source appropriately. Do not copy and paste information.
B. If Darryl McFadden was your child, what questions would you ask the doctor on the first office visit?
3. General questions:
A. Define in your own words the four types of word parts.
B. Identify each of the major body planes related to where they cross the body.
week 2
Musculoskeletal System and Patient Encounters (graded)
Class, in this thread we will be looking at musculoskeletal system terminology and related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in Terminal
Discharge Summary
Admission Diagnosis: Multiple compression fractures of T12, L1, L2, and L4
Discharge Diagnosis: Same as above, non-acute fractures
History of Present Illness: This is a 70-year-old African-American female with a long history of multiple fractures dating back to 1992. She has a history of significant osteoporosis diagnosed in 1998. The patient also has a history of osteoarthritis and had a right total hip replacement in 2000. Two days prior to admission, the patient missed the final step coming down the stairs in her home. She caught hold of the railing but twisted as she did so and developed some back pain. This became progressively worse over the next 2 days to the point where she was having difficulty ambulating and she went to the Emergency Room.
On evaluation in the ER, it was noted that she had compression fractures of the T12, L1, L2, L3, and L4 vertebrae. However, these could not be ruled out as new or old fractures due to lack of previous X-rays in this area. The patient was admitted for further evaluation.
Past Medical History: The patient is retired and lives in an independent living apartment in the Pine Valley retirement community. She does not smoke and has no alcohol intake. She has osteoporosis and osteoarthritis. Also of note is that approximately 10 days prior to admission, the patient had sustained a distal radius fracture of her left forearm for which she was treated with a splint by an orthopedist.
Physical Examination: This is a well-developed, well-nourished elderly female in no acute distress. She had moderate discomfort on movement. Her HEENT exam was essentially normal. Her lungs were clear. Heart had a regular rate and rhythm. Abdomen was soft and nontender. Her rectal area showed good tone. Her back showed moderate tenderness to palpation in the upper lumbar and lower thoracic area. Neurologically, she was completely normal with cranial nerves being intact. Motor was 5/5 in all extremities except for the left extremity, which was not examined secondary to the arm being in a splint. She had deep tendon reflexes 2+ and equal. Her sensory exam was normal.
Hospital Course: The patient was admitted and on the day following admission, she had a bone scan that revealed moderate degenerative joint disease of the T&L (thoracic and lumbar ) spine with no evidence of acute compression fractures. The patient was placed on bed rest and was started with physical therapy and ambulation with which she has steadily progressed with decreasing pain and tenderness. The patient is now ambulating using a walker with a platform for her wrist splint.
Social Services and Physical Therapy were consulted. She is ambulating well with her walker and it is felt she will do well staying with members of her family over the next 10 to 14 days, after which time she will be able to go back to living in her apartment.
The patient will follow up with the Orthopedic Clinic in 10 to 14 days. She will follow up with her private physician for the wrist fracture upon discharge.
Discharge Medications: Tylenol #3, one or two p.o. q 4-6 h. p.r.n.; Fosamax 5 mg daily, and she will continue with her Calcium t.i.d.
OUTPATIENT OFFICE ENCOUNTER
Carol Champion is a 46-year-old retired professional ice skater who was seen initially by Physical Therapy on 12/30/10. She indicates that she fell on her left shoulder and arm while ice skating on 12/29/09. She was first seen by Beth Ranowski and given Codman’s exercises. The patient continued to have shoulder pain and saw Dr. Owens on 1/04/10 and was referred for physical therapy due to her complaints of limited range of motion in the left shoulder secondary to pain. Her assessment was rotator cuff of the left shoulder with limitations in active range of motion.
DISCUSSION QUESTIONS:
1. Reviewing the Discharge Summary, provide the following in your post.
A. What does it mean in the spinal X-ray when it says, “These could not be ruled out as new or old fractures?”
B. What other terms in this case study refer to structures and conditions of the musculoskeletal system?
2. Reviewing the outpatient encounter of Carol Champion, accomplish the following and report in your findings and comments in your post.
A. Go to Research a Disease or Condition in the A.D.A.M. multimedia encyclopedia. Read all the information under rotator cuff tendinitis and look at the images. Read shoulder arthroscopy under the Read More section. Read one of the Care Points . Go to CLINICAL ILLUSTRATIONS (outside the encyclopedia on the ADAM home page) and look at isometric exercise .
B. After studying the material, summarize or paraphrase any information that you use in response to the discussion questions this week. Be sure and cite your source appropriately. Do not copy and paste.
C. What advice would you offer Carol Champion regarding what she should do if the physical therapy does not resolve the shoulder pain?
3. General questions:
A. What are the major structures of the bone and their respective subcategories?
B. Define each term into its common word parts. Write these word parts in sequence; use a slash when necessary to indicate a combining vowel.
1) Bursectomy
2) Osteochondroma
3) Osteomalacia
4) Periostitis
5) Tendonitis
6) Spondylosis
week 3
Cardiovascular, Lymphatic, and Respiratory Systems Case Studies (graded)
Class, in this thread we will be looking at cardiovascular, lymphatic, and respiratory systems and their related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in Terminal
Case Study
History: Nancy Macron is a 53-year-old female who states that she was doing well until about 1 month ago when she developed dyspnea on exertion, as well as nocturnal dyspnea and orthopnea (breathing discomfort occurring or made worse by lying flat ). She also complained of peripheral edema over that period of time. The patient gives a history of atypical chest discomfort located over the left breast, described as a dull ache. This has no relationship to exertion and is not relieved by rest. She denies a prior history of coronary artery disease or prior history of myocardial infarction in the past.
Her risk factors are negative for hypertension or diabetes mellitus. She does admit to tobacco use, about one pack per day over the past 5 years, down from two packs a day over the preceding 20 years.
Family History: Her family history is negative for coronary artery disease.
Allergies: None
Medications: Medications include Lanoxin 0.125 mg daily, Slow-K 8 mEq t.i.d., and Lasix 40 mg a day.
Operative History: She gives a history of cholecystectomy 5 years ago. Carcinoma of the colon was discovered and treated 10 years ago.
Physical Examination: General: She is a well-nourished, well-developed, obese female in no acute distress. Blood pressure was 130/80 and pulse was 100 and regular. Her weight was 213 pounds and height 5’3.” HEENT: Head is atraumatic, normocephalic. Eyes: Pupils equal, round, and reactive to light, the sclera was clear, and the conjunctiva was pink. Neck: Supple. There is a good carotid upstroke noted bilaterally. The thyroid was noted to be midline. No bruits were appreciated. Chest and Lungs: Clear to A & P (auscultation and percussion ) without rales, rhonchi, or wheezes appreciated. Cardiac: S1 and S2 were heard, no S3 (first through third heart sounds ). No murmurs were appreciated.Abdomen: Bowel sounds were audible and felt to be normal. I was unable to palpate the liver or spleen. Extremities: Negative for cyanosis, clubbing, or edema.
Impression: The history is compatible with congestive heart failure. However, at this time, the patient is not in congestive heart failure. This most likely is secondary to the fact that she is on Lanoxin, Lasix, and Slow-K. Except for smoking, the patient does not have any risk factors. I have proceeded to evaluate her cardiac function by ordering a chest X-ray to evaluate cardiac size, an echocardiogram with Doppler to evaluate left ventricular function, and a stress test with Thallium to evaluate for the presence of coronary artery disease.
Thank you very much for allowing me to see this patient. After the studies have been completed, a follow-up letter will be forwarded.
OUTPATIENT OFFICE ENCOUNTER
Sarah Eubanks is a 65-year-old female who recently had a mammogram that showed a focal abnormality in the superior aspect of the right breast. Nothing was palpable; however, the surgeon felt that this area should be removed. Prior to presenting to the operating room, the abnormality was localized with a Kopan’s wire placed under mammogram guidance. After the mass was excised, the pathology report indicated that microscopic examination revealed a lesion that was 0.8 cm in diameter. The post-op diagnosis was infiltrating ductal carcinoma.
DISCUSSION QUESTIONS:
1. Reviewing the case study and provide the following in your post:
A. Choose one body system, describe its major structures and functions, and then explain the terms used in this case study that relate to that system.
B. Reviewing the patient’s case study, list all diagnoses past and present, and define word parts where appropriate.
2. Reviewing the outpatient encounter of Sarah Eubanks, accomplish the following and report in your findings and comments in your post:
A. Go to Research a Disease or Condition in the A.D.A.M. multimedia encyclopedia. Read all the information under Cancer – breast and look at the six images. Read one of the Care Points . Go to CLINICAL ANIMATIONS (outside the encyclopedia on the ADAM home page) and look atLymphatics and the breast .
B. After studying the material, summarize or paraphrase any information that you use in response to the discussion questions this week. Be sure and cite your source appropriately. Do not copy and paste.
C. Given Sarah’s diagnosis, discuss what you consider the most likely prognosis and treatment?
3. General questions
A. Describe the primary functions performed by the cardiovascular, lymphatic, and respiratory systems.
B. Given your understanding of how the heart works as a result of the reading assignments for this week, what causes the heart sounds that are heard on auscultation? What are murmurs?
C. Name some other abnormal heart sounds and their significance.
week 4
Digestive and Urinary Systems Case Studies (graded)
Class, in this thread we will be looking at digestive and urinary systems and their related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in Terminal
Operative Report
Preoperative Diagnosis: Acute cholecystitis
Postoperative Diagnosis: Acute cholecystitis with partially gangrenous gallbladder
Operation: Laparoscopic converted to open cholecystectomy
Anesthesia: General
Estimated Blood Loss: 150 cc
Urine Output: 100 cc
Intravenous Fluids: 2500 cc of lactated Ringer’s
Complications: None
Findings: A partially gangrenous but mostly inflamed gallbladder with up to 1 cm thick gallbladder wall and multiple (greater than 50–100) small stones, each measuring approximately 2–4 mm
Description of Procedure: The patient was brought into the OR and placed in the supine position on the operating table. After successful endotracheal intubation, general anesthesia was safely achieved. Her entire abdomen was prepped with Betadine and draped in a sterile fashion. A 2.5-cm supraumbilical transverse incision was made for placement of a Verres needle to achieve pneumoperitoneum and the intra-abdominal cavity was insufflated with CO2 with difficulty. After the fascia on each side of the midline was secured with stay sutures, a knife blade was used to open the fascia and the 10-mm trocar was placed at this site. Upon insertion of the laparoscopic camera, no bowel injury was detected. A 10-mm trocar was then placed in the epigastric position at the midline. Two 5-mm ports were placed in the right upper quadrant, one around the nipple line just below the costal margin and the other around the anterior axillary line again below the costal margin. Through one of the 5-mm ports, an endoscopic needle attached to a 60-cc syringe was inserted in order to aspirate the content within the lumen of the gallbladder, which appeared to be extremely inflamed with what appeared to be a very thick peritoneal layer around the gallbladder.
Further dissection was made with a dissector introduced through the epigastric port. When the dissection was carried out down to the level of the gallbladder neck/cystic duct junction, the inflammation of the tissue around this region was so severe that it precluded a safe dissection of this area. The operation was therefore converted from laparoscopic to open cholecystectomy.
After the instruments and trocars, as well as the camera, were withdrawn from the incision sites, a skin incision was made between the epigastric site and the superior right upper quadrant 5-mm port site. The peritoneum was safely entered through this right subcostal incision. A Michotte retractor was placed cranially in order to retract the superior part of the operative field. Prior to opening the subcostal incision, the umbilical port site was closed at the fascial layer using a figure-of-eight suture. With the Michotte retractor in place, the superior portion of the wound was retracted open and several Mikulicz pads were placed within the abdomen to push the small bowel, colon, and stomach away from the operative field. A Kelly clamp was then placed over the fundus of the gallbladder and the peritoneum was scored with electrocautery. The gallbladder was then dissected off of the liver bed using electrocautery from the fundus down toward the neck. Portions of the peritoneal layer were approximately 1-cm thick. Several neovascularizations were noted within this thickened, inflammatory layer of tissue. Hemostasis was achieved using electrocautery. Several larger vessels from the neovascularization were ligated off with suture ties. Much of the gallbladder was shelled off of this inflammatory layer on the liver bed. The cystic artery was identified and ligated and divided between sutures. The cystic duct was also identified. The cystic duct/gallbladder neck junction was clearly identified in a retrograde fashion. The bottom of the gallbladder neck was clamped with a right-angle clamp, and the cystic duct/gallbladder neck junction was ligated with 2-0 silk tie. An additional 2-0 silk tie was placed to reinforce the ligature. The gallbladder was then resected and opened on the back table and sent to pathology. After successful resection of the gallbladder, the liver bed was inspected for any site of hemorrhage. The operative field was irrigated with antibiotic-soaked solution. A JP drain was then placed within the liver bed and brought out through the inferior right upper quadrant trocar site and secured to the skin with a suture.
After adequate hemostasis was achieved and confirmed, the irrigation fluid was aspirated from the abdominal cavity and the surgical wound was closed using PDS sutures. The skin was approximated using a skin stapler. All of the wounds were dressed with sterile gauze and secured with Tegaderm dressing. The patient tolerated the procedure well and there were no complications. The patient was extubated at the end of the case. All sponge and instrument counts were correct at the end of the case.
OUTPATIENT OFFICE ENCOUNTER
Bernard Collins is a 75-year-old male who has a long history of trouble urinating, along with frequent urinary tract infections. One month ago, an IVP done on February 2, 2010 showed a distended urinary bladder with a large postvoid residual. His symptoms include hesitancy and a decrease in the strength and force of his urinary stream. Physical exam reveals the prostate to be smooth, benign, and approximately 50 g in weight. We will discuss treatment options with the patient, including a TURP, when he returns in 1 week for follow-up.
DISCUSSION QUESTIONS:
1. After reviewing the Operative Report, provide the following in your post.
A. Please make a short summary of the above case. What procedure was intended? Why did it have to be converted? What were the abnormal findings? Be sure to explain any medical terms used in your response.
B. Reviewing the operative report, identify some key diagnosis and organs investigated during the procedure.
2. Reviewing the outpatient encounter Benard Collins, accomplish the following and report in your findings and comments in your post.
A. Go to Learn About a Test in the A.D.A.M. multimedia encyclopedia. Read all the information under Benign prostatic hypertrophy (hyperplasia) and look at the four images. View the video entitled Enlarged prostate gland . Look at Digital rectal exam in Clinical Illustrations (outside the encyclopedia on the ADAM home page).
B. After studying the material, summarize or paraphrase any information that you use in response to the discussion questions this week. Be sure and cite your source appropriately. Do not copy and paste.
C. Explain to Bernard in a way that he can understand what has happened to his prostate gland as a result of aging.
3. General questions:
A. Describe the primary functions performed by digestive and urinary systems.
B. What are the structures of the digestive system?
C. What are the structures of the urinary system?
week 6
Integumentary and Endocrine System Case Studies (graded)
Class, in this thread we will be looking at integumentary and endocrine systems and their related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in Terminal
OPERATIVE AND PATHOLOGY CASE STUDY
Preoperative Diagnosis: Multiple basal cell carcinoma temporal right lower lid
Anesthesia: Local
Operation: Pentagonal full thickness excision of multiple basal cells right lower lid; right lateral canthoplasty (surgical repair of the canthus )
Procedure: The patient, a 28-year-old Hispanic male, was brought to the operating room and placed in the supine position. Under nasal prong oxygen and cardiac monitoring, the right lower lid and surrounding area were anesthetized. The right face was prepped in the routine manner. The head and body were draped to expose the right eye.
Two, approximately 1.5-2.0 mm, round nodular ulcers centrally cratered, indurated lesions were outlined on the right lower lid not extending above the lateral canthal line. Medial to these lesions was a large milium (keratin-filled cyst ). A pentagonal incision was outlined incorporating approximately 1 cm of lid margin. A horizontal lateral canthotomy (surgical division of the slit between the eyelids ) was made and the tissue below it was undermined. The pentagonal incision, with the base being the lid margin, was then excised by outlining with mosquito forceps followed by scissors excision. Hemostasis was achieved with bipolar cautery. The lateral canthal flap was further undermined and the lateral canthal skin incision was extended approximately 0.5 cm temporally. The medial lid margin was then sutured to the lateral canthal ligament. The horizontal incision of the lateral canthotomy was closed and pentagonal lid gap was closed. Tobradex ointment and Telfa pad was placed and ice applied.
The patient tolerated the operation well and left the operating room in satisfactory condition.
Pathology Report
Clinical Data: Rule out malignancy, lesion of eyelid
Diagnosis: Basal Cell Carcinoma
Specimen Site: Eyelid
Gross Description: The specimen is received in formalin and labeled with the patient’s name. It consists of a 0.1 cm punch biopsy of light tan, wrinkled skin excised to a depth of 0.2 cm. On the surface, there is an irregularly pigmented area measuring 0.1 cm. Entirely submitted.
Microscopic Description: Sections of the submitted skin biopsy show a multicentric basal cell carcinoma. The tumor is formed by masses of small, darkly basophilic, ovoid cells that tend to palisade around the periphery. Marked basophilic degeneration of collagen is seen in the dermis. There is focal lymphocytic infiltration of the dermis. The tumor extends to margins of the biopsy.
OUTPATIENT OFFICE ENCOUNTER
Margaret Smith is a 61-year-old black female who presents with complaints of depression, weight gain, sensitivity to cold, joint and muscle pain, and fatigue. She states that she feels tired even after getting a good night’s sleep. In addition, she has gained 20 pounds over the past 3 months, which she says is atypical for her because she has maintained a relatively constant weight of 140 pounds over the course of the past 30 years. She finds that she must wear a jacket whenever she stays in an air-conditioned room, even if the room temperature is moderate. She also notes dry and cracked skin, especially around her heels and must apply moisturizers twice a day, which have not seemed to alleviate the excessive dryness.
DISCUSSION QUESTIONS:
1. Given one or two common medical terms found in the Operative and Pathology reports, deconstruct the components of specific medical terms to identify their meaning.
2. Reviewing the outpatient encounter of Margaret Smith, accomplish the following and report in your findings and comments in your post.
A. Go to the A.D.A.M. multimedia encyclopedia and click on Research a disease or condition . Under hypothyroidism , read all the material under the main headings. Look at the four images.
B. After reading the material, summarize or paraphrase any information that you use in response to the discussion questions this week. Be sure and cite your source appropriately. Do not copy and paste information.
C. Discuss possible causes of Margaret’s hypothyroidism. What are some early symptoms of this disorder? What are the risk factors for developing hypothyroidism?
3. General questions
A. Describe the structures of the skin.
B. Describe the structures of the end
week 5
Nervous and Special Senses Systems Case Studies (graded)
Class, in this thread we will be looking at nervous and special senses systems and their related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in Terminal
CASE STUDY
Mrs. Markus is a 37-year-old woman with a history of migraine headaches and visual field disturbances. She has a left medial lower quadrant defect (an area of reduced visual function ) that was noted in December of 1999 and has been stable. She recently developed a right temporal lower quadrant defect, which was first noted in September of 2004 and has had worsening symptoms in October.
An MRI in November showed a normal study of the brain including visual cortex and periventricular white matter, with a normal study of the orbits, optic nerves, and extra ocular muscles. A pituitary microadenoma (small benign tumor of the pituitary gland ) of approximately 3 mm on the left side of the gland was found with no compromise of the optic chiasm. Mrs. Markus underwent further evaluation by MRI with pituitary cuts and the microadenoma was again noted left of midline causing no compression of the optic nerves nor invasion of the cavernous sinus. The microadenoma is approximately 5 mm.
Past medical history is also significant for depression, asthma, and a hiatal hernia. Her current medications include Prozac, Imitrex, and Azma
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