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University of Phoenix Material
Symptom Analysis and Organization of Data for Written Record
Scenario 1: Mrs. D., a new patient, comes to see you because of fatigue. She is a known diabetic.
Each sentence or phrase of the history and physical examination is presented in random order. First, identify which ones are essential pieces of information when writing a chart note. Then organize the data into a standard format by labeling each item as listed below:
ID = Identifying Statement
CC = Chief Complaint
HPI = History of Present Illness
PMH = Past Medical History
MEDS = Medications, Vitamins, Herbals
Allergies = Allergies to foods, drugs, pollens
FH = Family History
SH = Social History
ROS = Review of Systems
S = Subjective Date
O = Objective Data
A = Assessment
P = Plan
_____ The lungs are clear to percussion and auscultation.
_____ Mrs. D. was born near Rochester, completed high school, and worked as a sales clerk for several years before marrying. She is 63-years old.
_____ She had pneumonia 3 times last year.
_____ She had systolic murmur grade II/VI.
_____ Scarlet fever at age 8.
_____ One son, age 40, alive and pre-diabetic.
_____ Four years ago, after gaining about 15 pounds to her present weight of 150, Mrs. D. first noted fatigue, polyuria, and polydipsia.
_____ Father died age 65 of myocardial infarction.
_____ For several months, some dull occipital headaches.
_____ Range of joint motion is full.
_____ At home glucose 295.
_____ Fasting triglycerides 586.
_____ Pelvic and rectal examination is deferred until next visit.
_____ Full oral polio immunization.
_____ Last tetanus booster 8 years ago. No Pneumovax or shingles vaccine.
_____ Appendectomy, age 15.
_____ Mother died, age 63, of a cerebrovascular accident; mother had diabetes and hypertension.
_____ The mortgage is paid on their small house, but savings are few.
_____ Mrs. D. is an obese, short, women.
_____ Mrs. D. is a 65-year-old, recently widowed, white women.
_____ Per patient, she has had no serious illnesses, and her general health has been good.
_____ Reflexes are 2+ and symmetrical, with down-going plantar responses.
_____ Heberden’s nodes on both hands.
_____ The hair is gray and of normal texture
_____ The tongue is coated.
_____ The trachea is midline; the thyroid is not felt.
_____ Intermittent mild aching of knees and hips.
_____ The abdomen is obese and non-tender, no organs or masses are felt due to obesity.
_____ Mrs. D. has two children, both of whom are now married and live out of town.
_____ After the diagnosis of diabetes, a weight reduction regimen was instituted but was unsuccessful. She was started on metformin three and one-half years ago
_____ She has not had serious accidents.
_____ She presently takes 1.0 grams of metformin twice daily.
_____ She comes to the clinic complaining of fatigue.
_____ Menopause at age 45.
_____ She communicates easily but become tearful when talking of her husband’s death.
_____ Pulse 76, regular; blood pressure 140/85; respiration 16, weight 162 pounds.
_____ Some redness and retraction of the gums.
_____ Cervical and axillary nodes are not palpable.
_____ Breasts are symmetrical without masses.
_____ Since her husband died rather suddenly of an acute myocardial infarction; she has had trouble adjusting to his death and has become increasingly fatigued.
_____ Sclerae is clear, conjunctiva is pink and moist
_____ Extraocular movements are intact; pupils are equa,l round, and react to light and accommodation; the fundi show early signs of narrowing of vessels at the crossing.
_____ One daughter, age 36. alive and well.
_____ There is some edema, +2 bilaterally, and the dorsalis pedis and posterior tibial pulses are +1.
_____ Tempanic membrane is intact.
_____ She has been sleeping poorly, awakening in the early morning hours. Up to void x3/night.
_____ The nasal septum is deviated to the left, but the airway is clear.
_____ Per patient, there are no present symptoms of diabetes.
_____ Post pharynx rises with “ah”. Post pharynx with exudative pustules, post pharynx with cobble stoning, etc.
1. Symptom Analysis
|PQRST |OLDCARTS |
| |[Previous Occurrence] |
| | |
|Precipitating factors |Onset |
| | |
|Quality |Location |
| | |
|Region or radiation |Duration |
| | |
|Severity |Characteristics |
| | |
|Temporal factors |Aggravating |
| | |
|Results of treatment |Relieving |
| | |
|Significant negatives |Treatment |
| | |
| |[Severity] |
| | |
2. What elements are involved in the coding process?
Scenario 2: Mrs. D’s Revisit
A short note on Mrs. D’s revisit has been randomized. Organize the data into the problem-oriented format by labeling each item as listed below:
S = Subjective
O = Objective
A = Assessment
P = Plan
_____ Urine sugar today negative.
_____ Is not tearful today.
_____ We shall continue to support and accept grieving.
_____ Has lost 5 pounds.
_____ Diabetes better controlled.
_____ Is taking metformin BID.
_____ Sleep improved.
_____ Polyuria and polydipsia have resolved.
_____ Depression improving.
_____ Continue diet and metformin.
_____ Getting out with friends more.
Using the information provided above in the revisit, complete the symptom analysis in the table below.
3. Symptom Analysis
|PQRST |OLDCARTS |
| |[Previous Occurrence] |
| | |
|Precipitating factors |Onset |
| | |
|Quality |Location |
| | |
|Region or radiation |Duration |
| | |
|Severity |Characteristics |
| | |
|Temporal factors |Aggravating |
| | |
|Results of treatment |Relieving |
| | |
|Significant negatives |Temporal |
| | |
| |[Severity] |
| | |
4. What elements are involved in the coding process?
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