Read the medical record below. Write out five medical terms, abbreviations, or acronyms from the record and define them. This assignment isn’t timed.
CC: Epigastric pain
HPI: This 66-year-old male presents for a re-evaluation of his epigastric pain. He continues to report epigastric pain secondary to chronic pancreatitis. He states he has also been diagnosed with a tumor on his pancreas, and he is going to begin chemotherapy. He is taking MS Contin 60 mg at 7 a.m. and 9 p.m. This does help his pain without side effects. He denies renal or hepatic dysfunction.
Active Problems:
1. Chronic pancreatitis
2. Hypercholesterolemia
3. Essential hypertension
4. Degenerative arthritis of both hands
5. h/o right hip fx in 2009
PHYSICAL EXAM: Reveals a well-developed, well-nourished patient in no acute distress. He is alert and answers questions appropriately. HEENT: Head is normocephalic, atraumatic. NECK: Supple with no thyromegaly. ABDOMEN: There is no tenderness to palpation throughout the abdomen. There is no rebound tenderness. CARDIOVASCULAR: Regular rate and rhythm. RESPIRATORY: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. EXTREMITIES: No clubbing, cyanosis, or edema.
IMPRESSION:
Chronic epigastric pain secondary to chronic pancreatitis
PLAN:
Rx MS Contin 60 mg at 7 a.m. and 9 p.m.
RTO in 3 months
Type your list or chart into a Microsoft Word document or a Notepad document. Be sure to save your file using this naming protocol: lastname_firstinitial_Assignment7. So if your last name is Jones and your first name is Wanda, you would name your file Jones_W_Assignment7. Then use the “Browse” button below to locate the file on your computer and the “Upload this file” button to send it to your facilitator.
