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November 28, 2014

Homework Help: Med terms

Posted by Rachel on Tuesday, July 12, 2011 at 2:17pm.

I am having troubles finding all 10 mistakes and need some help.
Inpatient Progress Report
Attending Physician: Moreover, Cindy

Patient: Stephen R. Peters
DOT: 03/01/19XX

CHIEF COMPLAINT: This 53-year-old man visited the outpatient clinic for dyspnea and recurrent coughing.

HISTORY OF PRESENT ILLNESS: This patient has a long history of Chronic Constructive Pulmonary Disease (CODP). He was treated for bronchitis and afonia twice last year. Nebulizer treatments are conducted in the home 3 times a day and at every clinic visit. There is a productive cough with spudum being mucopurulent however airway is patent. Chest X-ray (CXR) indicates possible fluid in the lower left lobe of the lung. A Chest Computed Tomography (CT) Scan reveals a suspicious lesion in the left lower lobe of the lung with diffuse interstitial fibrotic lesions. Pulmonary Function Test (PFT) reveal lower measurement in breathing from last visit and Pulse Oximetry indicates 91 percent oxygen saturation with 142 heartbeats per minute. In May 2007, the patient underwent a sleep study, was diagnosed with severe sleep eupnea and prescribed a CPAP ventolator to be used during any sleep period.

Over the last 10 dailys, the patient has had at least 25 episodes of dyspnea; all relieved by a bronchodilator inhaler. Most recent episode of dysphnea was yesterday and the prescribed inhaler gave no relief for almost 15 minutes before subsiding to another puff of the inhaler. He went to the emergency room (ER) yesterday for a nebulizer and parioxysm treatment. This patient is a current smoker and indicates a consumption of 2-3 packs of cigarettes per day and has not discussed the need to stop at this point.

PHYSICAL EXAM: On exam today, blood pressure is 158/92. He has tachycardia with a pulse of 152. He is in no acute distress. Crackles heard in lungs with little air exchange in both right and left sides. Small air movement on the right lower lobe and no movement in the left lower lobe of the lungs can be heard. There is no edema or distention of neck veins.

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