Devry Hit 111 Complete Course – Latest 2015

DEVry HIT 111 Complete Course – Latest 2015

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week 1

Patient Documentation Analysis (graded)

Class, in this thread we will be looking at patient documentation and patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in Terminal Course Objectives (TCOs) 1 and 2. You must address all of the questions located after the example of surgical history and patient encounter of Darryl McFadden.

SURGICAL HISTORY

History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and vomiting. The initial onset of the pain was about 48 hours prior to presentation. The pain was progressive in nature and began radiating to the back. Late yesterday, the patient drank some Alka-Seltzer and went to bed. He was awakened during the night by the pain and began vomiting. The patient states the pain is constant and has localized to the right lower quadrant. His last bowel movement yesterday afternoon was normal. He does have a history of irritable bowel syndrome; however, he states that this pain is different than the pain he has had in the past.

Past Medical History: Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable.

Past Surgical History: Tonsillectomy and adenoidectomy in early childhood; umbilical hernia repair at age 4.

Medications: None

Allergies: No known drug allergies

Social History: The patient is employed as a computer programmer. He is married and has no children. He has smoked a half a pack of cigarettes daily for the last 10 years. He drinks alcohol rarely.

Family History: Both parents are alive and well. One sister has Down syndrome. Paternal grandfather has COPD,...