Abstracting Medical Record

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Directions:
For this medical record abstracting assignment, first click the following link to access the medical record for a patient with a respiratory system concern. MEdical record attached below

 

 

When you have examined the entire medical record document, click the link below to download the list of questions related to that record. Save your answers in this document and submit them for this module’s assignment. worksheet is attached below as well

 

Health Record Face Sheet

Record Number: 004

Age: 76

Gender: Male

Length of Stay: NA

Service: Subsequent Hospital Visit

Disposition: Home

SUBJECTIVE:

This 76 year old patient indicates he is still short of breath. No nausea or vomiting. He does have occasional chest pain. The patient is a poor historian. He is not sure if it is exertional. The patient denies orthopnea. The patient is well known to this hospital service due to previous multiple admissions. The patient denies nausea or vomiting. Last bowel movement was within the last 24 hours, normal character. No palpitations or dizziness.

OBJECTIVE:

VITAL SIGNS: Blood pressure 106/76, pulse 110, respirations 22, temperature is 37.2 Celsius. The patient remains afebrile. Telemetry demonstrates atrial fibrillation with occasional rapid ventricular response, occasional heart rate in the 120s.

GENERAL: In no acute distress. The patient is awake, alert and appropriate responsive.

HEART: Irregularly irregular with a 4/6 systolic ejection murmur, left sternal border consistent with mitral regurgitation.

LUNGS: Left greater than right basilar crackles. No wheezes. Mild prolonged expiratory phase.

ABDOMEN: Positive normoactive bowel sounds, soft, mild diffuse tender to palpation without rebound or guarding.

EXTREMITIES: No clubbing or cyanosis. Trace pretibial edema. Calves are nontender to palpation. Warm and well perfused.

PERTINENT LABORATORY: Sodium 140, potassium 4.5, BUN is down from 41 to 40, creatinine down from 1.7 to 1.6 and glucose 210. Admission labs are noted. Chest x-ray was ordered and pending.

IMPRESSION:

1. Acute exacerbations, chronic diastolic congestive heart failure and severe pulmonary hypertension.

2. Severe pulmonary hypertension.

3. Severe mitral regurgitation, 4+ by echocardiogram in 10/2008.

4. Questionable nursing home acquired pneumonia. The patient’s white blood count is normal. The patient is afebrile. We will continue to treat empirically. We will follow chest x-ray in clinic progress.

5. Acute on chronic renal insufficiency slightly improved.

6. Do not resuscitate.

7. Coronary artery disease.

8. History of atrial fibrillation. The patient is not on Coumadin therapy, currently stable, does have occasional rapid ventricular response.

9. History of seizure disorder currently stable.

PLAN:

1. I did have long discussion with the patient’s son, did confirm DNR status. The patient due to diastolic nature of his congestive heart failure will be volume sensitive and will need gentle diuresis; however, given the severity of his mitral regurgitation will be somewhat more aggressive in diuresis.

2. We will add to blood and lab, Dilantin level, cardiac enzymes, troponin I, magnesium and D-dimer.

3. We will change diet to 2 g sodium American Heart Association diet.

4. We will recheck a.m. lab.

5. We will order accurate I’s and O’s. The patient is currently declining Foley catheter.

6. We will order daily weights.

7. We will give Lasix 40 mg IV push x1 now and repeat in 8 hours.

8. We will start Cardizem 30 mg p.o. q.8h. hold for systolic blood pressure less than 100 or heart rate less than 60 to hopefully minimize the patient’s risk for rapid ventricular response on his atrial fibrillation as well as increase myocardial relaxation and hopefully improve his diastolic CHF.

9. We will recheck portable chest x-ray in the morning.

John Doe, MD

3 | Page

Diagnosis and Management of Eye, Ear, Nose, and Throat Disorders

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Diagnosis and Management of Eye, Ear, Nose, and Throat Disorders

 

 

 

Case Study 2:

 

 Kaitlyn is a 4-year-old with a 2-day history of nasal congestion and cough in the early morning. Her mother reports thick, green nasal discharge. She is afebrile, and appetite and sleep are normal. Physical examination reveals: lungs clear to auscultation, tympanic membranes pearly gray without fluid in a neutral position, no cervical adenopathy, nasal turbinates are red, and clear rhinorrhea and postnasal drip.

 

To prepare:

 

•Review “Eye Disorders” and “Ear Disorders” in the Burns et al. text.

 

•Review your selected  case studies. Analyze the patient information, including the parent’s perspective.

 

•Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.

 

•Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.

 

•Consider strategies for educating parents on the child’s disorder and reducing any concerns/fears presented in the case study.

 

:

 

Post 1 to 2 page paper on  : An explanation of the differential diagnosis for the patient in the case study you selected.

 

Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis.

 

Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments.

 

Finally, explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.

 

 

 

References

 

Readings

 

• Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.

 

◦Chapter 28, “Eye Disorders” (pp. 622–651)

 

◦Chapter 29, “Ear Disorders” (pp. 652–668)

 

American Academy of Pediatrics. (2004). Clinical practice guideline: Diagnosis and management of acute otitis media. Pediatrics, 113(5), 1451–1465.

 

 

 

Chow , A.W., Benninger, M.S., Brook, I., Brozek, J.L., Goldstein, E.J.C., Hicks, L.A., Pankey, G.A., Seleznick, M., Volturo, G., Wald, E.R., & File Jr, T.M. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases , 54(8), 72-112.

 

Write several broad instructional goals for the educational experience.

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Instructional Unit: Goals, Objectives, and the Teaching Plans

This week you will submit your instructional unit, which should include three lesson plans: one focused on patient education, one on family education, and one on staff development. Remember, your plans should demonstrate a logical approach to teaching, communicate what is to be taught and how, and outline how objectives are to be evaluated. Click here for a refresher on what each final lesson should include.

Building on the work that you started in Week 2, for all three groups of learners:

  • Write several broad instructional goals for the educational experience.
  • Write several behavioral objectives based on Bloom’s taxonomy.
  • Describe the lesson content.
  • Provide a sequence for teaching activities.
  • Describe instructional methods.
  • Indicate time allotted for each activity.
  • Identify and describe the instructional resources (materials, tools, etc.) and technology to be used.
  • Describe how the learning will be evaluated.

On a separate references page, cite all sources using APA format.

  • Use this APA Citation Helper as a convenient reference for properly citing resources.
  • This handout will provide you the details of formatting your essay using APA style.
  • You may create your essay in this APA-formatted template.

Submit your response in a 6- to 7-page paper

[Type text] [Type text] [Type text]

 

 

COURSE CODE: NSG4028 Concepts of Teaching and Learning WEEK 4

  Unsatisfactory

1

 Emerging

2

 Proficient

3

 Exemplary

4

 Score
Assignment Components
Listed two broad instructional goals for the educational experience for each of the three groups of learners. Did not include instructional goals for the educational experience and/or did not include all learners. Minimally listed broad instructional goals for the educational experience and included two of the three groups of learners. Listed several broad instructional goals for the educational experience and included all learners. Goals could be more clearly stated. Expertly stated several broad instructional goals for the educational experience and included all learners. [Score x 4 = 16 pts]
Listed learning objectives that addressed the cognitive capabilities of each of the three groups of learners. Did not include learning objectives that addressed the cognitive capabilities of the learner and/or did not include all groups of learners. Minimally listed learning objectives that addressed the cognitive capabilities of the learner and included two of the three groups of learners Listed learning objectives that addressed the cognitive capabilities of the learner and included all learners. Objectives could be more clearly stated. Expertly stated learning objectives that addressed the cognitive capabilities of the learner and included all learners. [Score x 4 = 16 pts]

 
Listed learning objectives that addressed the affective capabilities for each of the three groups of learners. Did not include learning objectives that addressed the affective capabilities of the learner and/or did not include all learners. Minimally listed learning objectives that addressed the affective capabilities of the learner and included two of the three groups of learners. Listed learning objectives that addressed the affective capabilities of the learner and included all learners identified. Objectives could be more clearly stated. Expertly stated learning objectives that addressed the affective capabilities of the learner and included all three groups of learners. [Score x 4 = 16 pts]

 
Listed learning objectives that addressed the psychomotor capabilities of each of the three groups of learners. Did not include learning objectives that addressed the psychomotor capabilities of the learner and/or did not include all learners. Minimally listed learning objectives that addressed the psychomotor capabilities of the learner and included two of the three groups of learners. Listed learning objectives that addressed the psychomotor capabilities of the learner and included all learners. Objectives could be more clearly stated. Expertly stated learning objectives that addressed the psychomotor capabilities of the learner and included all learners identified. [Score x 4 = 16 pts]

 
Provided an appropriate description of the lesson content Provided a description of the lesson content but was not clearly focused or coherent. Minimally Provided an appropriate description of the lesson content. Provided an appropriate description of the lesson content, but could be more detailed. Provided a description of the lesson content that was appropriate, thorough, and detailed.

 

 [Score x 4 = 16 pts]
Provided a sequence for teaching activities and time allotted for each activity. Provided a sequence for teaching activities and time allotted for each activity but was not clearly focused or coherent. Minimally provided a sequence for teaching activities and time allotted for each activity Provided an appropriate sequence for teaching activities and time allotted for each activity, but could be more detailed. Provided a thoroughly detailed sequence for teaching activities and time allotted for each activity. [Score x 4 = 16 pts]

 
Described the instructional strategies Description of the instructional strategies was not clearly focused or coherent. Provided a minimal description of the instructional strategies. Provided an acceptable description of the instructional strategies, but could be more detailed. Thoroughly described the instructional strategies in detail. [Score x 4 = 16 pts]

 
Identified and described the instructional resources and technology Identified and described the instructional resources and technology but was not focused or coherent.. Minimally identified and described the instructional resources and technology Identified and described the instructional resources and technology but could be more detailed. Identified and thoroughly described the instructional resources and technology in detail. [Score x 4 = 16 pts]

 
Provided an evaluation methodology Provided an evaluation methodology but was not clearly focused or coherent. Provided an evaluation methodology with minimal information. Provided an acceptable evaluation methodology but could be more detailed. Thoroughly provided an evaluation methodology in detail. [Score x 4 = 16 pts]

 
Writing Components
Organization

Introduction

Thesis

Transitions

Conclusion

 Introduction is limited or missing entirely.

 

The paper lacks a thesis statement.

 

Transitions are infrequent, illogical, or missing entirely.

 

Conclusion is limited or missing entirely.

 

 

 Introduction is present but incomplete or underdeveloped.

 

The paper is loosely organized around a thesis that may have to be inferred.

 

Transitions are sporadic.

 

Conclusion is present, but incomplete or underdeveloped.

 

 Introduction has a clear opening, provides background information, and states the topic.

 

The paper is organized around an arguable, clearly stated thesis statement.

 

Transitions are appropriate and help the flow of ideas.

 

Conclusion summarizes main argument and has a clear ending.

 

 Introduction catches the reader’s attention, provides compelling and appropriate background info, and clearly states the topic.

 

The paper is well organized around an arguable, focused thesis.

 

Thoughtful transitions clearly show how ideas relate.

 

Conclusion leaves the reader with a sense of closure and provides concluding insights.

 [Score x 3 = 12 pts]

 
Usage and Mechanics

Grammar

Spelling

Sentence structure

 Writing contains numerous errors in spelling, grammar, and/or sentence structure that severely interferes with readability and comprehension.

 

 Errors in spelling and grammar exist that somewhat interfere with readability and/or comprehension.

 

 

 

 Writing follows conventions of spelling and grammar throughout. Errors are infrequent and do not interfere with readability or comprehension. The paper is basically error free in terms of mechanics. Grammar and mechanics help establish a clear idea and aid the reader in following the writer’s logic.

 

 

 [Score x 3 = 12 pts]

 
APA Elements

Attribution

Paraphrasing

Quotations

 No attempt at APA format. APA format is attempted to paraphrase, quote, and cite, but errors are significant. Using APA format, accurately paraphrased, quoted, and cited in many spots throughout when appropriate or called for. Errors present are somewhat minor.

 

 Using APA format, accurately paraphrased, quoted, and cited throughout the presentation when appropriate or called for. Only a few minor errors present. [Score x3 = 12 pts]

 
 

 

       Subtotal  
Timeliness

 

         Late Work penalty:
        Total Score  

/ 180

 

 

 

 

  2

Neurological System Case Study

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Neurological System Case Study

A 35-year-old male is admitted to a hospital following a minor car accident. He was driving home and fell asleep at the wheel. This is the third accident he has had in the past year. He also falls asleep regularly at work, at the dinner table, at church, and, in fact, anywhere. When he becomes excited or enraged, he suddenly becomes weak and falls. At night, he often has bizarre, terrifying dreams. During these dreams, he feels as if he were paralyzed.

Based on the scenario given above, answer the following questions:

  • Describe how a nerve impulse is transmitted from one neuron to the next.
  • Compare the structure and functions of the CNS and PNS.
  • What is the probable diagnosis for this man’s condition?
  • What parts of the person’s brain could have been affected?
  • What sleep state do these symptoms resemble?
  • How would an electroencephalogram (EEG) look like during the sleep condition of this patient?
  • What type of treatments (physical or chemical) would you prescribe for the patient?