- Practice Exam 1 Case Studies Inpatient Record Patient 5 Discharge Summary Date Of Admission 2 3 Date Of Discharge 2 5 1 (126.72 KiB) Viewed 21 times
- Practice Exam 1 Case Studies Inpatient Record Patient 5 Discharge Summary Date Of Admission 2 3 Date Of Discharge 2 5 2 (118.24 KiB) Viewed 21 times
- Practice Exam 1 Case Studies Inpatient Record Patient 5 Discharge Summary Date Of Admission 2 3 Date Of Discharge 2 5 3 (82.88 KiB) Viewed 21 times
Practice Exam 1 Case Studies INPATIENT RECORD-PATIENT 5 DISCHARGE SUMMARY DATE OF ADMISSION: 2/3 DATE OF DISCHARGE: 2/5 DISCHARGE DIAGNOSIS: Full-term pregnancy-delivered liveborn male infant Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessively. Patient made an uneventful recovery. HISTORY AND PHYSICAL EXAMINATION-PATIENT 5 ADMITTED: 2/3 REASON FOR ADMISSION: Full-term pregnancy at 38 weeks PAST MEDICAL HISTORY: Previous deliveries normal and mitral valve prolapse ALLERGIES: None known CHRONIC MEDICATIONS: None FAMILY HISTORY: Heart disease-father SOCIAL HISTORY: The patient is married and has one other child living with her. REVIEW OF SYSTEMS: SKIN: Normal HEAD-SCALP: Normal EYES: Normal ENT: Normal NECK: Normal BREASTS: Normal THORAX: Normal LUNGS: Normal HEART: Slight midsystolic click with late systolic murmur II/VI ABDOMEN: Normal IMPRESSION: Good health with term pregnancy. History of mitral valve prolapse-asymptomatic. 150
Practice Exam 1 Case Studies PROGRESS NOTES PATIENT 5 DATE NOTE 2/3 Admit to Labor and Delivery. MVP stable. Patient progressing well. Delivered at 1:15 p.m. one full-term male infant. 2/4 Patient doing well. Mitral valve prolapse stable. The perineum is clean and dry, incision intact. Will discharge to home 2/5 PHYSICIAN'S ORDERS PATIENT 5 DATE ORDER 2/3 Admit to Labor and Delivery 1,000 cc 5% D/LR May ambulate Type and screen CBC May have ice chips 2/5 Discharge patient to home. DELIVERY RECORD PATIENT 5 DATE: 2/3 The patient was 3 cm dilated when admitted. The duration of the first stage of labor was 6 hours, second stage was 14 minutes, third stage was 5 minutes. She was given local anesthesia. An episiotomy was performed with repair. There were no lacerations. The cord was wrapped once around the baby's neck, but did not cause compression. The mother and liveborn baby were discharged from the delivery room in good condition. 151
Practice Exam 1 Case Studies LABORATORY REPORT-PATIENT 5 HEMATOLOGY DATE: 2/3 Specimen Results Normal Values WBC 5.2 4.3-11.0 RBC 4.9 4.5-5.9 HGB 13,8 13.5-17.5 HCT 45 41-52 MCV 93 80-100 MCHC 41 31-57 PLT 255 150-450 Enter five diagnosis codes and two procedure codes. PDX DX2 DX3 DX4 DX5 PP1 PP2 152