HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Putul Barua Patient ID: 135799 DOB: 1970 Age: 42 Sex: Male Room No.: CCU 4 Date of Admission/Date of Arrival: 01/07/2012 Admitting/Attending Physician: Simon Williams‚ MD Admitting Diagnosis: 1. Rule out myocardial infarction. 2. History of TB 3. Hemoptysis. 4. Status post embolectomy. Chief Complaint: Tightness in the chest‚ shortness of breath‚ fast heart rate. HISTORY OF
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A 62-year old diabetic black man presents in the emergency room with a swollen left leg with areas of blanching and blue mottling. A "foul odor" is coming from a dressed wound. The physicians remove the dressing and a brownish fluid is seeping from a wounded area. The fluid contains what appear to be small bits of the tissue. No pus appears to be present. The wound has a strong "rotten" odor. Five days earlier‚ while at his work as a farmer‚ he caught the leg in his manure spreader‚ sustaining a
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Typhus is caused by one of two types of bacteria: Rickettsia typhi or Rickettsia prowazekii . The form of typus depends on which type of bacteria causes the infection. Rickettsia typhi causes murine or endemic typhus. Endemic typhus is uncommon in the United States. It is usually seen in areas where hygiene is poor and the temperature is cold. Endemic typhus is sometimes called "jail fever." Murine typhus occurs in the southeastern and southern United States‚ often during the summer and fall. It
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Nursing Diagnosis Ineffective breathing pattern related to decreased lung expansion secondary to accumulation of fluid in the pleuralcavity Nursing Plan Objectives : Patients able to maintain normal lung function Criterion Results : Rhythm‚ frequency and depth of breathing in the normal range‚ the chest X-ray examinations didnot find any accumulation of fluid‚ audible breath sounds. Plan of action : Identify the causative factor.Rational: By identifying
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will need to know all of the information that is on this paper. Section 1: Supply the Prefix Definition Example Prefix 1. within (---cellular‚ -- cranial) Intra- 2. painful‚ abnormal‚ difficult‚ labored ( -tropy‚ --pnea) Dys- 3. on‚ upon‚ over (-dermal) Epi- 4. one ( -lateral) Uni- 5. below‚ incomplete‚ deficient (- tonic‚ --tension) Hypo- 6. beside‚ beyond‚ around‚ abnormal (-thyroid‚ --lysis) Para- 7. absence of‚ without A‚ an- 8. through‚ across‚ beyond
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Open Ileocolic Resection Presenting Complaint Mrs. PC is a 56 year old woman who is 5 days post op following an open ileocolic resection indicated for a stricture in the terminal ilium on a background of Crohn’s disease. History of presenting complaint Patient has been suffering from Crohn’s disease since 1990 and has been attending the gastroenterology clinic since then. She has had recurrent pain in her right lower quadrant for approx. six months with four/five loose bowl movements per day‚ continually
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Week 2 Assignment The 7 Steps for correct ICD coding Identify all terms in the diagnosis Locate each main term in the Alphabetic Index. Refer to any subterms indented under the main term. Follow cross-reference instructions if the needed code is not located under the first main entry consulted. Verify the code in the Tabular List. Read and be guided by any instructional terms in the Tabular List. Assign codes to the highest level of specificity. I. Identify the main term for each diagnostic statement
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Lymphatics web quest Suggested site- www.cdc.gov‚ feel free to use other reliable sites as well. 1. What animal can transmit Cryptococcus? Pigeons 2. Can dogs and cats get Cryptococcus? Yes 3. What is the infectious agent for Bubonic Plague? Bacterium Yersinia Pestis 4. By how much was the world population reduced during the Plague pandemic? Estimate of 450 million 5. What year (within the past 100 years) did the world experience a flu pandemic? 1918 6. What are 3 symptoms of chikungunya
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A Crime of Compassion A Crime of Compassion by Barbara Huttmann is a story between a nurse and the patient’s wishes to die. The story is about Mac who was a cop that came into the hospital complaining about a cough that seems hard to get rid of. Later test confirmed that he had lung cancer that leads him to be confinement to the hospital. After six months‚ he lost his hair‚ bone and youth. Due to his condition‚ It was normal for Mac to trigger a code blue which announce a patient life is threaten
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Dr Donna Harrison dictating Diagnostic Imaging Report Patient : Putul Barua ID 135799 Room No. CCU4 X-ray 10-0460 Referring Physician: Simon Williams‚ MD from pulmonology. Reason for exam is hemoptysis Date of exam is 01/10 Procedure: Ct scan of chest without contrast Findings: Ct scan of the chest was performed in 7 mm axial sections with no intrrveous contrast enhancement. Comparison is made to previous ct scans made during his admission last year. There is interval resolution of
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