In this course project assignment, you are presented with treatment notes for two different patients.

Treatment Notes often include medication orders, medication administration, and documentation of procedures, such as physical therapy, respiratory therapy, nutrition counseling, and radiation therapy. These notes include details regarding the type, length, and necessity of treatment. Treatment notes are important to track the execution of the patient’s treatment plan and monitor progression of his or her health outcomes.

You will be exploring the medical terminology used in these test results and will be asked to interpret the meanings of various words and abbreviations.

To complete this assignment, do the following:

  1. Download the treatment notes for the two patients:

    Michelle Gibbler Treatment Notes

    Todd Anderson Treatment Notes

  2. Download, complete, and submit the document below. This document contains questions you will answer regarding the treatment notes for each patient.

    Module 05 Course Project Assignment Template

    PATIENT Michelle Gibbler DOB 05/16/1984 AGE 32 yrs SEX Female PRN MG875244

    FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

    Patient identifying details and demographics

    FIRST NAME Michelle MIDDLE NAME – LAST NAME Gibbler SSN –

    SEX Female DATE OF BIRTH 05/16/1984 DATE OF DEATH – PRN MG875244

    ETHNICITY Not Hispanic or Latino

    PREF. LANGUAGE

    English

    RACE Black or African American

    STATUS Active patient

    CONTACT INFORMATION

    ADDRESS LINE 1 123 S. 45th St. ADDRESS LINE 2 – CITY Anytown STATE NY ZIP CODE 12345

    CONTACT BY Home Phone EMAIL Michelle.Gibbler

    @testpatient.com HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE – OFFICE EXTENSION

    FAMILY INFORMATION

    NEXT OF KIN Josephine Gibbler RELATION TO PATIENT Mother PHONE 5555555555 ADDRESS 2345 78th St

    Haverhill, OH 45636

    PATIENT’S MOTHER’S MAIDEN NAME

    Johnson

    Free cloud based EHR

    Patient chart – Patient: Michelle Gibbler DOB: 05/16/1984 PR… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…

    1 of 1 4/7/17, 5:11 PM

    Northstar Surgical Group

    5678 Sunshine Way #500

    Minneapolis, MN 99999

    Phone: (555) 555-5555

    Patient: Michelle Gibbler

    DOB: 05/16/1984

    Preoperative Diagnoses: Endometriosis, dysmenorrhea, hx of intrauterine device perforation and exploratory surgery

    Procedure Performed: Left salpingo-oophorectomy

    Intraoperative Findings:

    Perineum and vulva are without lesions. On bimanual examination, palpation revealed the uterus to be enlarged and retroverted. Intra-abdominal findings revealed normal liver margin, kidneys, and stomach. The left fallopian tube appeared to be normal size and showed evidence of a functional cyst. Multiple adhesions were present upon examination of the left ovary.

    Procedure Details:

    After informed consent was obtained, the patient was delivered to the OR and placed under general anesthesia. She was then prepped and draped in the usual, sterile manner. In a supine position, a Foley catheter was placed.

    A sagittal midline incision was made and fascia was divided. The peritoneum was entered and observed. Washings were obtained. Exploration of the abdomen revealed findings as noted above. A retractor was placed and bowel was packed. Clamps were placed on the left broad ligament to improve traction. The retroperitoneal spaces were opened by incising lateral and parallel to the left infundibulopelvic ligament. The left ovarian ligament was identified and two hemostats were placed across the ovarian ligament. Using the Mayo scissors, the ovarian ligament was transected and dissected down the broad ligament. The left ovary was dissected in a similar fashion. The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder. After the pelvis had been irrigated, excellent hemostasis was noted. Retractors were repositioned to allow exposure for the left salpingectomy. Borders of the fallopian tube were identified. The posterior border of dissection was the retroperitoneal cavity, which was carefully identified and preserved. Ligaclips were applied to the left suspensory ligament. The left fallopian tube was dissected proximally. The suspensory ligament was dissected at its tubal attachment site, allowing the fallopian tube to be extracted. After the left salpingectomy was performed, excellent hemostasis was noted. All packs and retractors were removed and the abdominal wall was closed using a permanent monofilament suture. Irrigation of subcutaneous tissues was performed and a Jackson-Pratt drain was placed. At the completion of the procedure, all instrument, sponge, and needle counts were correct.

    The patient was taken to the recovery are and then awakened from her anesthetic in stable condition.

    Physician’s Signature John R. Benjamin, MD

    Northstar Physical Therapy

    6789 Sunshine Way #600

    Minneapolis, MN 99999

    Phone: (555) 555-5555

    Patient: Michelle Gibbler

    DOB: 05/16/1984

    Referring Physician: Nazir Asaad, MD

    Diagnoses/Reason for PT Referral: Hx of Endometriosis and dysmenorrhea; 2 weeks post-surgical LSO

    Onset date: 2/5/15 Relevant S&S: Pelvic pain, lumbalgia, metrorrhagia

    Plan of Care

    Interventions:

    X Evaluation Gait training X Electrotherapy

    X Patient Education Balance training/activities Prosthetic training

    X Therapeutic Exercise Pulmonary physical therapy TENS

    Transfer training X Ultrasound Teach bed mobility skills

    Use of adaptive device Teach fall safety X Heat/cold therapy

    X Therapeutic massage X Trigger point therapy

    Treatment Frequency: Office visit 2x/wk for 6 weeks Modalities:

    Patient education- Educate patient on muscular control for Kegal exercises. For 20 reps. Therapeutic exercise- Guided nutation/counternutation of the SI joints 10 reps x3

    Therapeutic massage- Myofascial release 30 min Ultrasound- SI joints 10 min @ 1MHz; anterior pelvis 10 min @ 1MHz Electrotherapy- Interferential electrical stimulation 20min @ 80-150Hz – L-S spin Trigger point therapy- PRN (hip rotators, iliopsoas, QL, abdominals) Heat/cold therapy- Heat before tx, cold post-tx. Alternating heat/cold at home Physical Therapy Goals:

    Current Level Goals

    Moderate urinary incontinence daily Eliminate incontinence

    Moderate-Severe pelvic pain rated 6/10 on average

    Reduce pain to 3/10 over 6 weeks; re-evaluate for further therapy to eliminate pain

    Tolerance to ADLs: Mod-severe pain is limiting work performance

    Tolerance to ADLs: No pain, leading to no limitation to work performance

    Pelvic/abdominal cramping at least 1x/week Eliminate pelvic/abdominal cramping

    Discharge Plan: Re-evaluate after 6 weeks of treatment (12 visits)

    Rehabilitation Potential:

    Poor Fair Good X Excellent

    Physical Therapist’s Signature Olivia Pham, D.P.T.

    PATIENT Todd K Anderson DOB 03/05/1970 AGE 47 yrs SEX Male PRN JR572205

    FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

    Patient identifying details and demographics

    FIRST NAME Todd MIDDLE NAME K LAST NAME Anderson SSN 123-12-2311

    SEX Male DATE OF BIRTH 03/05/1970 DATE OF DEATH – PRN JR572205

    ETHNICITY Hispanic or Latino

    PREF. LANGUAGE

    English

    RACE White STATUS Active patient

    CONTACT INFORMATION

    ADDRESS LINE 1 45 Deer Run Road

    ADDRESS LINE 2 – CITY Livingston STATE NJ ZIP CODE 07039

    CONTACT BY Email EMAIL todda@testpatie

    nt.com HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE – OFFICE EXTENSION

    FAMILY INFORMATION

    NEXT OF KIN Jessie Anderson RELATION TO PATIENT Spouse PHONE 5555555555 ADDRESS 45 Deer Run Ln

    Livingston, NJ 07039

    PATIENT’S MOTHER’S MAIDEN NAME

    Free cloud based EHR

    Patient chart – Patient: Todd K Anderson DOB: 03/05/1970 PRN… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…

    1 of 1 4/7/17, 5:12 PM

    Northstar Surgical Group

    5678 Sunshine Way #500

    Minneapolis, MN 99999

    Phone: (555) 555-5555

    Patient: Todd K Anderson

    DOB: 03/05/1970

    Indications: Patient with large renal calculus.

    Procedure: Percutaneous Nephrolithotomy

    The patient was placed in the supine position, given general anesthesia, then prepped and draped in the usual standard sterile manner. A flexible cystoscope was then placed into the urethral meatus and the length of the urethra inspected. No lesions noted.

    The bladder neck and trigone showed no abnormalities. The ureteral orifices were noted to be normal bilaterally. A routine inspection of the bladder was completed with no sign of obvious lesions. A cone tip catheter was placed into the ureteral orifice. Under fluoroscopic visualization, a retrograde ureteropyelogram with diluted contrast was performed. No obvious lesions were noted. A 0.3 guide wire was passed through the ureter and into the renal pelvis. An urteral occlusion balloon catheter was passed over the wire and the balloon was inflated with contrast. The bladder was drained, wires removed, scope removed under direct vision.

    The patient was then repositioned in the prone position, prepped and draped again in the usual, sterile manner. A 0.04 guide wire was passed through the previously placed nephrostomy tube. The nephrostomy tube was then removed over the wire. The tract was dilated to accommodate an introducer sheath of 10 French size. A safety wire was passed into the renal pelvis and into the ureter past the ureteral occlusion balloon and secured for emergency use. Sequential dilation was performed to insert a fascial dilator balloon. This balloon was inflated with contrast to 20 atmospheres of pressure under fluoroscopy over a period of 5-10 minutes. Then, a 30 French sheath was passed over the balloon into the inter-renal calyx. The balloon was deflated and removed. The nephroscope was introduced. An inspection of the renal pelvis identified the stone. No lesions were identified. The stone was fragmented with an ultrasound lithotripter. Larger fragments of calculi were removed intact with forceps until the patient was free of all calculi. The renal collecting system was inspected with the nephroscope and flexible nephroscopy to verify no additional stone material remained. Fluoroscopy was used to verify the absence of stone material. The guide and safety wires were removed. The nephrostomy tube was secured to the skin with a nylon suture. The cook catheter was capped. The wound was cleaned and bandaged. Patient was then awakened from anesthesia without complications and transferred to recovery. The patient is in stable condition and without complications.

    Physician’s Signature Selena Hensen, MD

    Northstar Nutritional Services

    4567 Sunshine Way #400

    Minneapolis, MN 99999

    Phone: (555) 555-5555

    Patient: Todd K Anderson

    DOB: 03/05/1970

    Referring Physician: Nazir Asaad, MD

    Medical Nutritional Care Plan Current Diagnoses: Nephrolithiasis

    Relevant S&S: Colic, Oliguria, Pyuria, Dysuria, Lumbalgia Relevant Lab Findings: Hematuria, dark amber urine

    Current BMI: 33.9 Estimated energy needs: 3283 calories per day Estimated protein needs: 56-72 grams per day Estimated carbohydrate needs: 179 grams per day Estimated fat needs: 40-45 grams per day Nutrition Prescription: Increase water consumption daily. Decrease sodium intake. (Patient provided with information on DASH diet.) Include more alkaline foods, such as root vegetables, leafy greens, garlic, lemon, and cayenne peppers. Switch to olive oil for cooking vegetables and lean meats. Calculation of therapeutic diet for certain disease states: Nephrolithiasis: Restrict high-oxalate foods; restrict animal protein Family hx of hypertension: Reduce sodium intake to below 1500 mg/day Family hx of gouty arthritis: Reduce meat and fish intake. Replace protein sources with dairy products and legumes. Nutrition-related medical condition goals: Intervention #1: Increase fluid intake Goal(s): High fluid intake will be this patient’s first priority intervention. Goal is to consume two liters of water daily. This fluid intake should be spread evenly throughout the day. Bladder should be emptied as needed. Voluntary urine retention is highly discouraged. Intervention #2: Alkalinize diet Goal(s): Due to family history of gouty arthritis (father and paternal GF), it is suggested that the patient alkalinize his diet to prevent uric acid lithogenesis. The measurable goal is to maintain a urine pH above 6.5 through hydration and potassium citrate solution (30 mEq/day). Counselor’s Signature Francie McClanahan, R.D.

 
Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount!
Use Discount Code "Newclient" for a 15% Discount!

NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.