Medical records skill check
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Last updated 3 months ago
25 questions
Case study 1
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 from 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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1
what is the age of the patient
what is the age of the patient
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What is the patients gender?
What is the patients gender?
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Which of the following is the patients CC?
Which of the following is the patients CC?
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Which of the following is the Best description of the patients rash?
Which of the following is the Best description of the patients rash?
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Which of the following observations are additional objective findings that can help in this case?
Which of the following observations are additional objective findings that can help in this case?
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What is the proper diagnosis for this Pt
What is the proper diagnosis for this Pt
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Which of the following is the prescribed treatment for the condition?
Which of the following is the prescribed treatment for the condition?
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Eyrthema is spelled incorrectly, what is the correct spelling?
Eyrthema is spelled incorrectly, what is the correct spelling?
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There are three additional spelling errors, locate them and write the correct spelling below. (example: smile, style, and stylus) (copy the formatting as shown in the example)
There are three additional spelling errors, locate them and write the correct spelling below. (example: smile, style, and stylus) (copy the formatting as shown in the example)
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What is the meaning of the abbreviation: y/o
What is the meaning of the abbreviation: y/o
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OTC stands for?
OTC stands for?
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Pt is short for
Pt is short for
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bid is an abbreviation for
bid is an abbreviation for
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RTC stands for
RTC stands for
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What is Seborrheic dermatitis
What is Seborrheic dermatitis
Part 2
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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1
Which of the following brought the patient to the doctors office?
Which of the following brought the patient to the doctors office?
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What is the patient already diagnosed with?
What is the patient already diagnosed with?
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IDDM stands for?
IDDM stands for?
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Was the patient put through any medical tests?
Was the patient put through any medical tests?
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What was the patients blood sugar at?
What was the patients blood sugar at?
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Which of the following is a good discription of the patients skin?
Which of the following is a good discription of the patients skin?
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What was the medication prescribed and administered?
What was the medication prescribed and administered?
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Which of the following medical tests are to be preformed regularly.
Which of the following medical tests are to be preformed regularly.
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"q4h" means to check the patient again in __________ hours
"q4h" means to check the patient again in __________ hours
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What is Diabetic Ketoacidosis?
What is Diabetic Ketoacidosis?