Abstracting medical record paper

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

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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. Abstracting medical record paper

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

Abstracting medical record paper