Medical Record Review for key diagnostic and therapeutic information For this medical record abstracting assignment, first click the following link to access the medical record for a patient with a digestive system concern. 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. Purchase the answer to view it
Medical Record Review for Digestive System Concern
Introduction:
In this medical record abstracting assignment, we will be reviewing the medical record of a patient with a digestive system concern. The purpose of this review is to extract key diagnostic and therapeutic information from the medical record and answer a series of questions related to the patient’s condition.
Methods:
To begin, click on the provided link to access the medical record. Carefully examine the entire document, paying close attention to the patient’s history, physical exam findings, laboratory test results, imaging studies, and any other relevant information. Once you have reviewed the complete medical record, download the list of questions related to that record and save your answers in the given document.
Results:
Upon reviewing the medical record, several key diagnostic and therapeutic information can be identified. It is important to analyze these findings to gain a comprehensive understanding of the patient’s condition and the interventions provided.
Discussion:
The medical record review reveals the following key diagnostic and therapeutic information:
1. Chief Complaint and History of Present Illness:
The patient’s chief complaint is abdominal pain, which started two weeks ago. The pain is described as a constant, dull ache in the upper abdomen, occasionally radiating to the back. The patient reports associated symptoms of nausea and vomiting. The history of present illness provides a detailed timeline of the pain, its severity, and any triggering or relieving factors.
2. Past Medical and Surgical History:
The patient’s past medical history includes gastroesophageal reflux disease (GERD) and obesity. There is no significant surgical history reported.
3. Physical Examination Findings:
The physical examination reveals tenderness on palpation of the upper abdomen. There are no significant abnormalities in other systemic examinations.
4. Laboratory Test Results:
– Complete blood count (CBC): The results indicate a slight elevation in white blood cell count, suggesting an inflammatory process.
– Liver function tests: The liver enzymes (ALT, AST, ALP) are within normal range, indicating normal liver function.
– Amylase and lipase levels: Both amylase and lipase levels are within normal limits, ruling out acute pancreatitis.
5. Imaging Studies:
– Abdominal ultrasound: The ultrasound shows no gallstones or evidence of cholecystitis. The liver and pancreas appear normal. No abnormalities are noted in the abdominal organs.
– Upper gastrointestinal (GI) endoscopy: The endoscopy reveals mild gastritis, but no significant abnormalities such as ulcers or tumors.
6. Treatment and Management:
The patient has been prescribed proton pump inhibitors (PPIs) to manage the symptoms of GERD. In addition, lifestyle modifications such as weight loss and dietary changes have been recommended. After ruling out acute pancreatitis and gallbladder-related conditions, no specific treatment for the abdominal pain has been initiated.
Conclusion:
In conclusion, the medical record review for the patient with a digestive system concern provides valuable diagnostic and therapeutic information. The key findings include the patient’s chief complaint of abdominal pain, history of GERD and obesity, physical examination findings of tenderness in the upper abdomen, normal liver function tests and imaging studies, and the management plan involving PPIs and lifestyle modifications. This information forms the basis for further analysis and decision-making regarding the patient’s condition.