Medical Reports Resource: Medical Language Accelerated Review the following notes taken from a medical report

A 51-year-old male presents to your office with left lower abdominal pain, diarrhea, nausea, and vomiting. He states that he has a decreased appetite along with a low-grade fever and chills.
November 13, 2019
Module 6 Teena Kissee Case Study I What are the potential ICD-10 codes in this case? 1. a. 2. How can the NP determine if the patient v/s an established patient at the clinic?
November 13, 2019

Medical Reports Resource: Medical Language Accelerated Review the following notes taken from a medical report

Medical Reports Resource: Medical Language Accelerated Review the following notes taken from a medical report. Medical Report 1 Vital Signs: Temperature: 98.9 Heart Rate: 86 Respiratory Rate: 16 Blood Pressure: 180/102 General: Patient appears pleasant, well nourished, with noted distress during “stabbing” pain in chest ENT Exam: Normal Lungs: Mild crackles, patient unable to take a deep, full breath. Heart: No murmus, no rubs, regular rate and rhythm. Abdomen: No guarding or rigidity, no hernia notes, normal bowel sounds, soft, non-tender, no distention Neurologic: Normal, alert and oriented. Medical Report 2 Mrs. Smith initial diagnosis of Pulmonary Hypertension. I have ordered blood work: CBC, CMP TSH, PT, PTT and CPK. Echocardiogram, and Chest X-ray also ordered. Patient to be admitted to the cardiac floor for 24 monitoring, cardiac consult and to complete ordered tests. Medical Report 3 Patient: Shirley Smith Date of Birth: 11/11/1947 Sex: Female Mrs. Smith is a 69 year old, white female who presents today with chief complaint of “stabbing chest pain radiating down left arm, lasting for 2 days. Pain Scale: 7/10 currently, last night 10/10. Patient reports worsening symptoms last night, with pain waking her from sleep. Mrs. Smith reports no history of similar symptoms, and no modifying activities relieve the pain. Patient reports no known family history of heart conditions. Currently patient has no known drug allergies, and currently does not take medications. Medical Report 4 Final diagnosis and treatment plan to be discussed with patient and family following results of tests and 24 monitoring.

 

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