In this course project assignment, you are presented with a full medical chart for one individual patient. An entire medical record can be very lengthy and challenging to navigate. You will see some familiar sections of a medical record that were covered in Modules 02-05, as well as various other notes and details pertaining to this patient.
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You will be exploring the medical terminology used in this medical record and will be asked to find information and interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
- Download the full medical record for the one patient:
Nancy Jackson-Davis Full Medical Record
- Download, complete, and submit the document below. This document contains questions you will answer regarding the medical record for the patient.
Module 06 Course Project Assignment Template
PATIENT
NancyR Jackson-Davis
DOB 04/08/1982
AGE
35 yrs
SEX Female
PRN NO731672
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
Patient identifying details and demographics
FIRST NAME Nancy
MIDDLE NAME R
LAST NAME Jackson-Davis
SSN
–
SEX Female
DATE OF BIRTH 04/08/1982
DATE OF DEATH –
PRN NO731672
ETHNICITY Not Hispanic or
Latino
PREF.
LANGUAGE
English
RACE Black or African
American,Asian
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 321 S. 54th St
ADDRESS LINE 2 –
CITY Anytown
STATE NY
ZIP CODE 12345
CONTACT BY Home Phone
EMAIL NancyJD@testpat
ient.com
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN Scott Davis
RELATION TO PATIENT Spouse
PHONE 5555555555
ADDRESS 345 56th St
Anytown, NY 12345
PATIENT’S MOTHER’S
MAIDEN NAME
Halifax
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 10 4/8/17, 9:18 AM
Vitals flowsheet – Nancy R Jackson-Davis
02/08/17
7:35 AM
03/06/17
7:44 AM
03/31/17
2:00 AM
Vitals
Height 62 in 62 in 62 in
Weight 145 lb 142 lb 137.99 lb
BMI 26.52 25.97 25.24
BMI Percentile
BP 138/68 mmHg 126/67 mmHg 125/88 mmHg
Temperature 98.4 °F 98.6 °F 98.9 °F
Pulse 76 bpm 68 bpm 76 bpm
Respiratory rate 14 bpm 16 bpm 10 bpm
O2 Saturation
Pain
Head Circumference
Chronic Diagnoses
ACTIVE DIAGNOSES START STOP
(K58.0) Irritable bowel syndrome with diarrhea 02/08/2017
Medication Viberzi Start: 04/08/17
(K21.9) Gastro-esophageal reflux disease without esophagitis 02/08/2017
Medication Omeprazole
Medication Omeprazole Start: 03/06/17
(K44.9) Diaphragmatic hernia without obstruction or gangrene 02/08/2017
HISTORICAL DIAGNOSES START STOP
(Z33.1) Finding related to pregnancy 07/04/2009 04/16/2010
Acute Diagnoses
ACTIVE DIAGNOSES START STOP
(K59.00) Constipation, unspecified 03/06/2017
HISTORICAL DIAGNOSES START STOP
(O20.0) Threatened abortion, antepartum condition or complication 07/17/2014 07/17/2014
(N36.9) Unspecified disorder of urethra and urinary tract 02/08/2014 02/08/2014
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
2 of 10 4/8/17, 9:18 AM
Drug Allergies
ACTIVE ALLERGIES SEVERITY/REACTIONS ONSET
Patient has no known drug allergies
Food Allergies
ACTIVE ALLERGIES SEVERITY/REACTIONS ONSET
No food allergies recorded
Environmental Allergies
ACTIVE ALLERGIES SEVERITY/REACTIONS ONSET
No environmental allergies recorded
Active Medications
MEDICATION SIG START/STOP ASSOCIATED DX
Eluxadoline (Viberzi) 75 MG Oral
Tablet
04/08/17 – IBS with diarrhea
Omeprazole 10 MG Oral Capsule
Delayed Release
– GERD
Provider comment: b.i.d. by Nazir Ashaad on 04/08/17
Omeprazole 20 MG Oral Capsule
Delayed Release
03/06/17 – GERD
Smoking History
STATUS EFFECTIVE DATE
No smoking history available for this patient
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
3 of 10 4/8/17, 9:18 AM
Past medical history
MAJOR EVENTS
Appendectomy (1992)
Fx radius and ulna (1998)
Pregnancy and vaginal delivery (2010)
ONGOING MEDICAL PROBLEMS
Hiatal hernia- Dx 2016; Monitoring, no tx to date
FAMILY HEALTH HISTORY
Father- Hypertension, hypercholesterolemia
Mother- Celiac disease
PGM- died of lung cancer
PGF- alive and in good health
MGM- Rheumatoid arthritis, inguinal hernia, unspecified bowel issues
MGF- Cardiovascular disease, stroke
PREVENTIVE CARE
Pap smears – no hx abnormal pap smear
Vaccinations:
Yearly influenza (most recent 2016)
DPT (2009)
Hepatitis B (approx 1996)
SOCIAL HISTORY
Married with one child. Reports safe, stable family environment.
Does not use alcohol, tobacco, other drugs.
Occupation: social worker
NUTRITION HISTORY
No current restrictions in diet.
DEVELOPMENTAL HISTORY
Normal
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
4 of 10 4/8/17, 9:18 AM
Chief complaint
Epigastric px, nausea, vomiting
Vitals for this encounter
No vitals recorded
PATIENT
Nancy R Jackson-Davis
DOB 04/08/1982
AGE 35 yrs
SEX Female
PRN NO731672
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
Office Visit
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 04/08/2017
AGE AT
DOS
35 yrs
Not signed
SUBJECTIVE
The patient returns for followup. She relates she has been doing well, except that since February, she has had epigastric
pain. She took omeprazole first once daily and then b.i.d. and felt somewhat better.
She took it for about a month and then tapered to off. Last week, she had an episode of hematemesis with bright red
blood. She reports she was not retching prior to the hematemesis. She had a dark stool, but no frank melena after that.
OBJECTIVE
Abdomen: Positive bowel sounds with mild epigastric tenderness. No rebound or guarding. No peritoneal signs. Rectal
Exam: No masses and brown Hemoccult-negative stool.
ASSESSMENT
Epigastric pain with an episode of hematemesis.
Diagnoses attached to this encounter:
(K58.0) Irritable bowel syndrome with diarrhea
PLAN
Recommend an upper endoscopy and order was put through for the same. The patient has no signs of active bleeding
and is currently Hemoccult negative from below. Restart omeprazole b.i.d. Check liver tests, CBC, amylase, lipase, and a
pregnancy test.
Medications attached to this encounter:
Eluxadoline (Viberzi) 75 MG Oral Tablet
Omeprazole 10 MG Oral Capsule Delayed Release
Free cloud based EHR
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
5 of 10 4/8/17, 9:18 AM
Chief complaint
No chief complaint recorded
PATIENT
Nancy R Jackson-Davis
DOB 04/08/1982
AGE 35 yrs
SEX Female
PRN NO731672
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
Office Visit
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 03/06/2017
AGE AT
DOS
34 yrs
Not signed
Vitals for this encounter
03/06/17
7:44 AM
Height 62 in
Weight 142 lb
Temperature 98.60 °F
Pulse 68 bpm
Respiratory rate 16 bpm
BMI 25.97
Blood pressure 126/67 mmHg
SUBJECTIVE
The patient is a pleasant 34-year-old female who presents today in gastroenterology clinic for followup of nausea,
vomiting, and reflux. The patient has been taking omeprazole twice per day and ranitidine at bedtime.
Her reflux has returned about 2x/week. She had isolated episodes of vomiting.
Constipation is new symptom that has been occurring over the past 4 days.
OBJECTIVE
Pain score 4/10 in the abdomen. Tenderness upon abdominal palpation in all four quadrants.
ASSESSMENT
Hiatal hernia seems to be stable. Reflux is no longer controlled by current dosage of omeprazole. Constipation needs to
be addressed.
Diagnoses attached to this encounter:
(K59.00) Constipation, unspecified
Acute
(K58.0) Irritable bowel syndrome with diarrhea
PLAN
Start viberzi q.i.d.
Continue omeprazole. Increase dosage to 20 MG.
Short term suppository laxative recommended.
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
6 of 10 4/8/17, 9:18 AM
Reassess effectiveness of medication change in one month.
Medications attached to this encounter:
Eluxadoline (Viberzi) 75 MG Oral Tablet
Omeprazole 20 MG Oral Capsule Delayed Release
Free cloud based EHR
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
7 of 10 4/8/17, 9:18 AM
Chief complaint
Abdominal pain, nausea, diarrhea
PATIENT
Nancy R Jackson-Davis
DOB 04/08/1982
AGE 35 yrs
SEX Female
PRN NO731672
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
Office Visit
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 02/08/2017
AGE AT
DOS
34 yrs
Not signed
Vitals for this encounter
02/08/17
7:35 AM
Height 62 in
Weight 145 lb
Temperature 98.40 °F
Pulse 76 bpm
Respiratory rate 14 bpm
BMI 26.52
Blood pressure 138/68 mmHg
SUBJECTIVE
The patient is a pleasant 34-year-old female who presents today in gastroenterology clinic for followup of nausea,
vomiting, and reflux.
HPI
She complains of sharp, epigastric abdominal pain of 3-4
months duration. The abdominal pain has been gradually worsening over the past 3-4 months. The pain has not
changed or worsened acutely. The pain is located in the epigastric region and left upper quadrant of the abdomen. It
does not radiate. The pain is relatively constant throughout the day and night but does vary in severity. She rates the
pain as 6/10 at its worst. She describes the pain as a “sharp, burning” pain. She has not tried taking any medicines to
relieve the pain. The pain is not alleviated with rest. She thinks the pain may be aggravated by throwing the football, but
he has also experienced the pain independent of playing football or exerting herself. The pain is not associated with a
particular food or eating, although she does endorse
occasional heartburn. She reports the pain may at times be worse on laying down, and it does wake her up at night.
She denies any abdominal trauma or injury. She endorses a 5lb weight loss over the past 3-4 months, decreased
appetite, and fatigue. She has experienced some nausea with the abdominal pain and has occasionally vomited.
ROS
General: Pleasant female in no acute distress.
HEENT: Not examined
Lymph nodes: Non-tender, no palpable masses
Neck: No masses
Cardiovascular: See vitals.
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
8 of 10 4/8/17, 9:18 AM
Lungs: Lungs clear to auscultation bilaterally; No wheezes or crackles
Abdominal:
Abdomen soft and non-distended with no scars or striations
No pulsatile masses, no abdominal bruits ascultated
Spleen not palpable, liver not palpable
Tender to palpation in epigastric region and left upper quadrant; No reflex tenderness; No guarding;
Murphy’s sign negative
Genitourinary:
No complaints of dysuria, nocturia, polyuria, hematuria, or
vaginal bleeding.
Musculoskeletal: She complains of lower back pain, aching in quality, approximately once every week after working in
her garden. This pain is usually relieved with Tylenol. She complains of no other arthralgias, muscle aches, or pains.
Neurological: She complains of no weakness, numbness, or incoordination.
OBJECTIVE
PE
General: Patient appears alert, oriented and cooperative.
Skin:Normal in appearance, texture, and temperature
HEENT: Scalp normal. Pupils equally round, 4 mm, reactive to light and accommodation, sclera and conjunctiva normal.
Fundoscopic examination reveals normal vessels without hemorrhage. Tympanic membranes and external auditory
canals normal. Nasal mucosa normal. Oral pharynx is normal without erythema or exudate. Tongue and gums are
normal.
Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or supraclavicular areas. Trachea is
midline and thyroid gland is normal without masses. Carotid artery upstroke is normal bilaterally without bruits. Jugular
venous pressure is measured as 8 cm with patient at 45 degrees.
Chest: Lungs are clear to auscultation and percussion bilaterally.
Abdomen: The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas;
a bruit is heard in the right paraumbilical area. No masses or splenomegaly are noted; liver span is 8 cm by percussion.
Extremities: No cyanosis, clubbing, or edema are noted. Peripheral pulses in the femoral, popliteal, anterior tibial,
dorsalis pedis, brachial, and radial areas are normal.
Nodes: No palpable nodes in the cervical, supraclavicular, axillary or inguinal areas.
Genital/Rectal: Normal rectal sphincter tone; no rectal masses. Stool is brown. Pelvic examination reveals normal
external genitalia, and normal vagina and cervix on speculum examination. Bimanual examination reveals no palpable
uterus, ovaries, or masses.
Neurological: Cranial nerves II-XII are normal. Motor and sensory examination of the upper and lower extremities is
normal. Gait and cerebellar function are also normal. Reflexes are normal and symmetrical bilaterally in both
extremities.
ASSESSMENT
DDX: IBS with diarrhea
GERD
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
9 of 10 4/8/17, 9:18 AM
Diagnoses attached to this encounter:
(K58.0) Irritable bowel syndrome with diarrhea
(K21.9) Gastro-esophageal reflux disease without esophagitis
(K44.9) Diaphragmatic hernia without obstruction or gangrene
PLAN
Start omeprazole b.i.d.
Monitor IBS symptoms over next month to assist in diagnosis. Food journal will be discussed at next visit.
The patient at this point will follow up in one month. She is encouraged that if symptoms worsen in the interim, she
should contact us. We did also discuss seeing a surgeon for repairing the hiatal hernia. However, at this point, the
patient’s symptoms are well controlled on medication and that does not appear necessary.
Medications attached to this encounter:
Omeprazole 10 MG Oral Capsule Delayed Release
Free cloud based EHR
Patient chart – Patient: Nancy R Jackson-Davis DOB: 04/08/19… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
10 of 10 4/8/17, 9:18 AM
Vendor Order 1704Q0Y0 added on 04/08/17
Other
PATIENT
Nancy R Jackson-Davis
DOB 04/08/1982
AGE 35 yrs
SEX Female
PRN NO731672
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 02/08/2017
AGE AT
DOS
34 yrs
Not signed
Orders
LAB ORDERS
1625 – Occult Blood, Fecal, IA
IMAGING ORDERS
No orders attached to this encounter.
Free cloud based EHR
Encounter – Office Visit Date of service: 02/08/17 Patient: Nan… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 1 4/8/17, 3:35 PM
Vendor Order 1704Q0YZ added on 04/08/17
Other
Imaging Order 1704Q0YF added on 04/08/17
Other
PATIENT
Nancy R Jackson-Davis
DOB 04/08/1982
AGE 35 yrs
SEX Female
PRN NO731672
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 04/08/2017
AGE AT
DOS
35 yrs
Not signed
Orders
LAB ORDERS
3638 – CBC W Auto Differential panel – Blood
44 – Lipase serum or plasma
68 – Amylase serum or plasma
94 – hCG (Pregnancy Test)
IMAGING ORDERS
1064 – Fluoroscopy Guidance for endoscopy of Stomach
Free cloud based EHR
Encounter – Office Visit Date of service: 04/08/17 Patient: Nan… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 1 4/8/17, 3:34 PM
Northstar Imaging Center
2345 Sunshine Way #200
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Nancy Jackson-Davis
DOB: 04/08/1982
RELEVANT CLINICAL HISTORY
S&S: Epigastric px, nausea, vomiting, single episode of hematemesis
Symptoms have persisted for several months with periods of remission. Most recently, patient
experienced an episode of hematemesis, consisting of bright red blood. Fecal occult blood test negative.
PROCEDURE PERFORMED: Exploratory upper endoscopy
PROCEDURE INDICATION: Patient is a 35-year-old female. An endoscopy is being performed to evaluate
for source of upper GI bleeding.
MEDICATIONS Topical Cetacaine spray delivered preoperatively. Throughout the procedure, IV Fentanyl
100 mcg in incremental fashion with careful monitoring of patient’s vital signs.
PROCEDURE IN DETAIL: Informed consent was obtained and risks, benefits and alternatives of the
procedure were explained. The patient agreed to proceed.
The patient was placed in the left lateral decubitus position. Medications were delivered as described
above. Upon achieving adequate sedation, the Olympus video endoscope was inserted orally, over the
dorsum of the tongue, and advanced through the pharynx, esophagus, and stomach until reaching the
duodenum. The duodenum appeared normal. The scope was then retracted to view the stomach. The
antrum and angularis appeared normal as well. The scope was retroflexed to visualize the entirety of the
stomach, including the rugal folds, body, and fundus of the stomach. Visualization of the body of the
stomach revealed a 3 cm diameter ulcer on the posteroinferior wall. Retroflexion view of the fundus of
the stomach showed evidence of a hiatal hernia, which was previously noted. The scope was then
anteflexed and retracted to view the distal esophagus. The esophagus showed no evidence of stricture,
neoplasm, or ulceration. Samples were obtained from the antrum to screen for Helicobacter and
additional samples were sent to pathology. The LES and remaining portion of the esophagus appeared
normal. The squamocolumnar junction appeared normal as well. The scope was then slowly removed
and the procedure terminated. The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION:
1. Hiatal hernia, as previously noted.
2. Type IV gastric ulcer- 3 cm diameter on posteroinferior body of stomach.
3. No esophageal abnormalities noted.
Physician’s Signature Derek A. Sandbuck, MD
Module 06 Course Project: Full Medical Record
Each question is associated with the medical record provided. Refer to this when answering each question. Please type your answer in the “Click here to enter text” space.
Patient – Nancy Jackson-Davis
Identify and describe the first diagnosis listed under the Chronic Diagnoses section.
Click here to enter text.
Which medication was prescribed for Nancy’s diagnosis of gastroesophageal reflux disease?
Click here to enter text.
Which anatomical organ did Nancy have removed in 1992?
Click here to enter text.
Which of Nancy’s relatives experienced a condition that could be described as “a protrusion of an abdominal organ”?
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Around 1996, Nancy received a vaccination that will protect which of her digestive organs?
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In Nancy’s physical examination, which two abdominal organs are explicitly noted?
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On her March 6th visit, Nancy received a prescription for a new medication. As noted in her medical chart, what is the medical abbreviation of how many times per day should she take this medication?
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On her April 8 office visit, Nancy reports a new symptom involving blood. Identify the medical term and define it.
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Nancy’s physician notes her pain complaints as “epigastric.” What does this mean?
Click here to enter text.
Throughout Nancy’s medical chart, a hernia is mentioned. What type of hernia does she have? Describe where it is and which anatomical structures are involved.
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On April 8, Nancy’s physician orders an imaging procedure. Name and define this procedure.
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On April 8, which lab test is ordered with the order number 1704Q0Y0? If this test were positive, it would mean blood is present in the _____.
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According to Nancy’s imaging report, which of the 3 anatomical regions of the small intestine was explored?
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In Nancy’s imaging report, what does the abbreviation LES stand for?
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Nancy’s imaging report notes a new finding that is not mentioned anywhere else in her medical chart. What is it?
Click here to enter text.
References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
Click here to enter text.
You will also likely need to use other course materials or resources to answer all of this assignment’s questions. If you used other references, cite them here:
Click here to enter text.
*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa
Select “References” on the left-hand panel and choose the type of reference you used.
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