HIM 2214 Module 2: Medical Record Abstracting.

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HIM 2214 Module 2: Medical Record Abstracting

Instructions: In this medical record abstracting assignment you will first need to download the history & physical document for a patient with cardiovascular issues. Save your answers to the following related questions in this document and submit them for this module’s assignment.HIM 2214 Module 2: Medical Record Abstracting.

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1. What is exertional chest pain?

2. Define the term orthopnea.

3. What is atrial fibrillation?

4. What are some of the possible causes (etiology) of atrial fibrillation?

5. What is meant by the statement “4/6 systolic ejection murmur”?

6. What are basilar crackles?

7. Define the term palpitations.

8. Define the term cyanosis.

9. Define the abbreviation BUN.

10. What is meant by exacerbation?

11. Define pulmonary hypertension.

12. What is congestive heart failure?

13. Describe the pathophysiology of congestive heart failure.

14. Define the term diuresis.

15. What is mitral regurgitation?

16. What is the purpose of ordering a cardiac enzymes test?

17. Which condition(s) is/are the drug Cardizem used to treat?

18. What is a foley catheter?

19. What are I’s and O’s?

20. Which condition(s) is/are the drug Lasix used to treat

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

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.HIM 2214 Module 2: Medical Record Abstracting.

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.HIM 2214 Module 2: Medical Record Abstracting.

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.HIM 2214 Module 2: Medical Record Abstracting.

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.HIM 2214 Module 2: Medical Record Abstracting.

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.HIM 2214 Module 2: Medical Record Abstracting.

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.HIM 2214 Module 2: Medical Record Abstracting.

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

HIM 2214 Module 2: Medical Record Abstracting.