Translation from Progress Note Assignment

Translation from Progress Note Assignment

HS111 Unit 6 Assignment 2 Template

Translation from Progress Note

DIRECTIONS: Read through the medical report listed below and the follow the directions listed after the report.

 

ABC Medical Center

7777 North West Street, Michigan 12345 – (555) 123-4567

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PATIENT NAME:         D. Martens                       MEDICAL RECORD:                 8888888         

DATE OF BIRTH:          3/26/1947                               DATE OF ADMISSION:            1/19/2015

 

PROGRESS NOTE

HISTORY:  Deana Martens is a 67-year-old Caucasian female who was brought to the hospital via an ambulance and subsequently admitted to the hospital on 1/19/2015 for dysphasia, dysphagia, and right hemiparesis.   Translation from Progress Note Assignment. Ms. Martens has history of HTN, and High Cholesterol. Husband states that patient is taking medication daily. No problems have been noted prior to 1 ½ hours ago when she began to show signs of right facial drooping and complained of cephalgia.  Husband states the patient was unable to drink her coffee without the liquid spilling down her face.  Per the husband, the patient was reaching in the cupboard for a dish, when her right arm started to fall. After sitting at the breakfast table, the patient began to rise, when she fell to the floor, and was unable to stand up without help. She showed a steady decline within minutes developing ataxia, dysphagia, and dysarthria. Translation from Progress Note Assignment

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OBJECTIVE FINDINGS:  Physical examination shows the patient was alert, and oriented x 2. Mild confusion noted to place. Gait was not assessed at this time due to hemiparesis. Grips were unequal. Right pupil was sluggish to respond to light. Right lower extremity was flaccid.   Blood pressure was 180/92 mm Hg. Pulse, 78. Respirations, 18. Temperature 98.7.  Chest radiograph, Urinalysis, CBC, PTT, Basic Chemistry Panel and ABGs were obtained. ABGs showed low 0₂ saturation.  CT scan showed negative for an intracerebral hemorrhage. A neurology consultation was obtained.  Neurologist confirmed the diagnosis of an ischemic stroke after an MRI of the brain demonstrated an ischemic area of the left cerebral cortex caused by a cerebral embolism. Translation from Progress Note Assignment

IMPRESSION:  Hemiparesis, HTN, Ischemic Stroke

TREATMENT SUMMARY: The patient was given Alteplase 0.9 mg/kg IV infused over 1 hour for first bolus. Continued with 0.81 mg/kg as continuous infusion over 60 minutes.  Mannitol was started IV post Alteplase infusion. Patient transferred to ICU.  Neuro checks ordered q 2 hrs.  On the second hospital day, the patient developed hypotension, N & V. Reglan given IV and normal saline was increased to 150 drops per minute for 2 hours, then titrated down to 75.  After 5 hours, patient BP was within normal limits, N & V subsided.  Aggrenox started one capsule bid.   Third day inpatient stay was unremarkable. Patient was transferred to medical floor.  PT/OT, speech therapy ordered. Neuro checks reduced to every 4 hours. No further decline noted. Fourth inpatient stay, patient responding to PT/OT well. Use of walker with one assist. Gait and grip improving. No further neurological deficits noted.  Discharge planning started. Rehabilitation facility recommended for continued PT/OT and speech therapy. Family educated on treatment plan, patient transferred to extended care facility for rehabilitation. Continue antiplatelet therapy. Informed patient and family to follow-up with neurologist one week after discharge from rehab. Translation from Progress Note Assignment

Translation from Progress Note

Translation from Progress Note PART 1: Using the information provided in Progress Note above, please complete the following information.

In this Assignment, imagine you are a medical professional working at ABC Medical Center. Your patient is Mrs. Martens. Her daughter, Rae Sibley, has just arrived from Colorado. She is concerned about her mother’s well-being. You will be meeting with the patient’s daughter to update her on what has occurred during her hospital stay, the subsequent transfer to the rehabilitation facility, and a discharge plan.Translation from Progress Note Assignment

Use the information from the Progress Note to update Rae Sibley on her mother’s condition. You will be translating the medical information from the report into layman’s terms in order for the patient and patient’s daughter to understand.

Please be sure use complete sentences, proper grammar, and spelling. You can use medical terms, however, you must also use layman’s terminology. Remember, it is your job to explain to the patient’s daughter what has occurred.  You may need to use outside sources. Translation from Progress Note Assignment

Your explanation to Rae Sibley should be 500 words or more. Cite your reference(s) in APA format at the end of your explanation.

Type your translation of the Progress Note below. Make sure to use layman’s terms in order for Rae to understand what has occurred.

Translation from Progress Note REFERENCE:  (APA formatted references are required – list them below)

PART 2 – For this part, you will be completing the crossword puzzle that is below the table.  Instead of entering your answers into the crossword puzzle, enter your responses in the table provided. Translation from Progress Note Assignment

Part 2:  Enter your responses to the crossword puzzle here. There are 20 answers
No.	Across	No.	Down
1		2
4		3
6		5
7		8
9		11
10		13
12		14
16		15
17		19
18
20

 

Across

1. Medical term for “fetus with a small head”
2. Region meaning “inferior to the umbilical”
3. Combining form for “urea, nitrogen”
4. Blood test used to determine the concentrations of oxygen-carrying components in erythrocytes
5. Prefix for “fast or rapid”
6. Medical suffix for “loosening, dissolution, separating”
7. Name of a skin lesion that is characterized as “flat, colored spot”Translation from Progress Note Assignment
8. Medical term for “painful or difficult urination”
9. Medical term for “inflammation of the vein”
10. Medical term for “expelling matter from the stomach through the mouth”
11. Medical term for “rapid loss of blood”

 

Down

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2. Medical term for fingers and toes.
3. Suffix for cell
4. Abbreviation for white blood cell.
5. Another term for urinate or void
6. Abbreviation for abdomen
7. Prefix for “normal or good”
8. Medical term for “pertaining to vision”
9. Prefix for “two”
10. Origin term for “name of person” Translation from Progress Note Assignment