Me2220X

Week 5 ME2220X Medical Records

Tracye Braden

UMA

Guerda Louissaint

ME2220X

02/25/2014

In a document (MS Word or WordPad) do the assignment based on the following directions and medical records. Save your file and attach the file to the assignment Dropbox for grading.

Review the following medical records.

Provide a definition for each of the underlined medical terms.

Identify one misspelled word in each medical record, noting proper spelling.

Define one additional medical term within each record that you are not familiar with.

MEDICAL RECORD 1

University Hospital and MedicalCenter

4700 North Main Street Wellness, Arizona 54321 (987) 555-3210

PATIENT NAME: William Graves CASE NUMBER: 20066-OPH

DATE OF BIRTH: 06/27/xx DATE: 04/05/xx

PROGRESS NOTE

SUBJECTIVE: Mr. Graves is a 66-year-old white man here today for his annualophthalmology examination. He has no current complaints. He has a family history of glaucoma in his brother.

He has a history of hypertension and type 2 diabetes mellitus. A pterygium was removed from

his right eye 5 years ago.

CURRENT MEDICATIONS: Glyburide 5 mg bid and Lopressor 50 mg bid.

ALLERGIES: None

OBJECTIVE

Visual Acuities: Aided: OD 2/25-2 OS 20/30-1 OU 20/25

Unaided: OD 20/100 OS 20/80-1 OU 20/80

Externals: 2-mm blepharoptosis OD. PERLA. EOMI.

Ophthalmoscopic: Lens: OS showed early cortical spokes

Disk: margins normal

Cup-to-disk ratio: 0.2 OU

Fundus: Within normal limits including DVM

Refraction: OD-1.00-0.50 x 90 20/20, OS-1.25-0.25 x 90 20/20

Tonometry: 14 mm Hg OD, 13 mm Hg OS.

ASSESSMENT: Patient has compoundmyopic astigmatismand presbyopia with mild diabetic retinopathy and grade II hypertension. He also shows an early cataract in the left eye....