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School
Rasmussen College, Saint Cloud *
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Course
1531
Subject
Medicine
Date
Apr 3, 2024
Type
docx
Pages
3
Uploaded by LieutenantParrot3973
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 1.
Identify and describe the first diagnosis listed under the Chronic Diagnoses section.
Irritable Bowel Syndrome(IBS) with diarrhea
2.
Which medication was prescribed for Nancy’s diagnosis of gastroesophageal reflux disease?
Omeprazole
3.
Which anatomical organ did Nancy have removed in 1992?
Appendix 4.
Which of Nancy’s relatives experienced a condition that could be described as “a protrusion of an abdominal organ”?
Maternal Grandmother
5.
Around 1996, Nancy received a vaccination that will protect which of her digestive organs?
Liver
6.
In Nancy’s physical examination, which two abdominal organs are explicitly noted?
The bowels and the liver
7.
On her March 6
th
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?
q.i.d means Quarter In Die; 4 times a day
8.
On her April 8 office visit, Nancy reports a new symptom involving blood. Identify the medical term and define it.
Hematemesis; a condtion that involves vomiting blood and the upper digestive tract
9.
Nancy’s physician notes her pain complaints as “epigastric.” What does this mean?
The upper abdomen area between the belly button and ribs Page 1 of 3
10.
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.
Hiatial Hernia; the upper abdomen; the stomach and the diaphragm
11.
On April 8, Nancy’s physician orders an imaging procedure. Name and define this procedure.
Flouroscopy Guidance for Endoscopy of Stomach; the dr uses a specifi tool to see inside the body
12.
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 _____.
Stool 13.
According to Nancy’s imaging report, which of the 3 anatomical regions of the small intestine was explored?
Duodenum
14.
In Nancy’s imaging report, what does the abbreviation LES stand for?
Lower Espohageal Sphincter
15.
Nancy’s imaging report notes a new finding that is not mentioned anywhere else in her medical chart. What is it?
A 3 cm diameter ulcer on the posterior wall of the stomach
References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
Gylys B.A., & Wedding M.E. (2013) Medical Terminology Systems: A Body System’s Approach 7th ed. https://content.learntoday.info/Learn/collegis/eBooks/Medical/OPS/
book.html?page=10
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:
National Library of Medicine
Medical Encyclopedia: MedlinePlus
Page 2 of 3
*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.
Page 3 of 3
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