(SOLVED) Practice Sheet 5 W-MT (written 5)
Discipline: Nursing
Type of Paper: Essay (any type)
Academic Level: Undergrad. (yrs 3-4)
Paper Format: APA
Pages: 1
Words: 254
Question
Practice Sheet 5 W-MT (written 5)
Convert the below dictated lines into Preoperative History and Physical Report transcription with appropriate format of chart note including headings and all the rules of chart note transcription
the sixty seven year old gentleman underwent ultrasound guided needle biopsy of the prostate during the trans rectal ultrasound a positive bladder mass was noted
he is now to undergo a cystoscopy for confirmation
current medications includes cardura four milligram by mouth every hour multiple vitamins Aspirin, lipitor
- allergies plant pollen
-
- past medical history hypertension
-
- past surgery transectomy and removal of lymphoma
-
- physical examination he appears well alert and oriented
-
- vital signs blood pressure one sixty seven over seventy nine pulse seventy respiration eighteen
-
- lungs clear
-
- heart rhythm is regular without murmur
-
- abdomen soft without masses or tenderness
-
- groin is normal.
-
- extremities no peripheral edema
-
- digital rectal exam(DRE) the prostate was smooth with benign consistency
-
- diagnosis possible bladder tumor
EXPERT SOLUTION (PREVIEW)
Converting the given details into a preoperative history and physical report,
- step 1
Patient Name :
Date :
Age : 67
Sex : Male
MR# ; ( Insert medical record number )
Chief Complaints:
- Positive bladder mass noted during ultrasound guided needle biopsy of the prostate
History of Present Illness:
- The patient underwent ultrasound guided needle biopsy of the prostate, during which a positive bladder
mass was found.
- He is now scheduled to undergo a cystoscopy for confirmation
Medications:
- Cardura 4mg, Orally every hour.
- Multiple Vitamins
- Aspirin
- Lipitor
Allergies:
- Plant pollen
Past Medical History:
- Hypertension
Past Surgical History:
- Transectomy and removal of lymphoma
Physical Diagnosis:
- General: The patient appears well, alert, and oriented.
- Vital signs: Blood pressure of 167/79 mmhg, pulse of 70 beats per minute, and respiratory rate of 18
breaths per minute
- Lungs: Clear
- Heart: Rhythm is regular without murmur
- Abdomen: Soft, without masses or tenderness
- Groin: Normal
- Extremities: No peripheral edema
- Digital Rectal Screening: The Prostate was smooth with a benign consistency
Diagnosis:
- Possible bladder tumor
Signature,
( insert physician name )
( insert physician signature)
