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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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