In this Project you will check the Progress Report the following. Next, you are going to identify the 10 mistakes that are listed in the record. The blunders could be misspellings, incorrect abbreviations, or misuse of a medical term. You should list all of them in the graph below beneath the heading “Medical Terminology Problem. After you have listed the errors, you need to identify the best term or abbreviation. Make sure you list these people in the graph and or chart below underneath the heading “Correct Term. At the end in the project make sure to list almost all applicable referrals and refer to them in APA file format.
Primary Street Medical center and Medical Center
6000 North Shrub Street ” Branch, Philadelphia 12345 ” (555) 123-4567
SUFFERER NAME: Leslie SunshineMEDICAL RECORD: 5555555
DAY OF DEATH: 04/04/1954DATE OF ADMISSION: 07/31/2013
PRIMARY COMPLAINT: Severe lower belly pain as well as the inability to void for the past 12 hours.
PRESENT ILLNESS: Sam Samuel is a 75-year-old Asian-American man who came into the emergency section at 3 am proclaiming that he was in wonderful pain and can not urinate.
He previously not recently been seen with a physician for several years but stated to be in good health except for “a tiny high blood pressure. The patient studies urinary rate of recurrence, noicturia x2, hesitancy, intermittency, disuria, and diminished pressure and good quality of the bladder system. In addition , he lamented of intermittent pain in the right detrás lumbar region, radiating to the right flank. He also has post-void dribbling and the experience of devoid of completely purged the bladder. Earlier today, he had hematuria at the end of urination as well as some bouts of N&D.
MEDICINE ALLERGIES: Probably none
CURRENT PRESCRIPTION DRUGS: Benadryl twenty-five mg. dailys, at bed time.
PHYSICAL EXAMINATION: Temperature 98. 6 F. Blood pressure 140/90. Pulse 98. Respirations twenty-four. Palpation with the abdomen shows a suprapubic mass approximately three fingerbreadths below the umbilicus, dull to percussion, and slightly soft.
IMPRESSION: Renal Pelvis distention caused by urinary outlet blockage, probably via benign prostatic hyperplasia.
PREPARE: Indwelling Foley catheter for relief of urinary obstruction. Imaging to incorporate a CAT check out, kidney ultrasound and IVR. Urinary consult. Labs to feature white blood vessels count, hemoglobin, hematocrit, blood urea nitrogen (BUA) and urinalnysis.
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