Medical records skill check

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25 questions

Case study 1

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Part 2

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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
#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.

what is the age of the patient

What is the patients gender?

Which of the following is the patients CC?

Which of the following is the Best description of the patients rash?

Which of the following observations are additional objective findings that can help in this case?

What is the proper diagnosis for this Pt

Which of the following is the prescribed treatment for the condition?

Eyrthema is spelled incorrectly, what is the correct spelling?

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)

What is the meaning of the abbreviation: y/o

OTC stands for?

Pt is short for

bid is an abbreviation for

RTC stands for

What is Seborrheic dermatitis

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.

Which of the following brought the patient to the doctors office?

What is the patient already diagnosed with?

IDDM stands for?

Was the patient put through any medical tests?

What was the patients blood sugar at?

Which of the following is a good discription of the patients skin?

What was the medication prescribed and administered?

Which of the following medical tests are to be preformed regularly.

"q4h" means to check the patient again in __________ hours

What is Diabetic Ketoacidosis?

This is not the correct diagnosis for this Pt. 

None of the above

Yellow, greasy, scaly across entire forehead from hairline to eyebrows & on external ears.  

Yellow, dry, and inflamed, found primarily along the shoulders and neck. 

Red, Dry, Flaky scabs, across the forehead. 

All the above

Which of the following brought the patient to the doctors office?

Vomiting

Nausea

Headache

Weight loss

Faint

Brain fog

Loss of balance

Fever

Bloody stool

Which of the following medical tests are to be preformed regularly.

Dialysis

Blood glucose

Cognitive assessment

Med Term test

Urinalyses

Blood draw