Medical records skill check

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.

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.