C. Notes from T. Ayers, ER Physician Assistant, to pt's PCP, Dr. R. Bailey Pt was evaluated in ER with c/o chest tightness, SOB and dyspepsia. Pt was concerned that he was having an MI. P and BP were WNL Lab test for cardiac enzymes and EKG to R/O MI was negative. UGI X-rays Dx a hiatal hernia. Instructed Pt to take OTC antacids p.r.n. 1 hour p.c. and at hs. Please follow up with pt for further tx. 18. ER: 19. PCP: 20. c/o: 21. SOB: 22. dyspepsia: 23. MI 24. P 25, BP: 26. WNL: 27. lab: 28. cardiac: 29. EKG: 30. R/O: 31. UGI: 32. Dx: 33. OTC: 34. p.r.n.: 35. p.c.: 36. hs: 37. tx: 38. Why might this patient have thought he was having an MI when he went into the ER?

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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Read the following medical record. Define the abbreviations and terms called out in the record, and then answer the questions that follow each medical record.
C. Notes from T. Ayers, ER Physician Assistant, to pt's PCP, Dr. R. Bailey
Pt was evaluated in ER with c/o chest tightness, SOB and dyspepsia. Pt was concerned that he
was having an MI. P and BP were WNL Lab test for cardiac enzymes and EKG to R/O MI was
negative. UGI X-rays Dx a hiatal hernia. Instructed Pt to take OTC antacids p.r.n. 1 hour p.c. and
at hs. Please follow up with pt for further tx.
18. ER:
19. PCP:
20. c/o:
21. SOB:
22. dyspepsia:
23. MI
24. P
25, BP:
26.WNL:
27. lab:
28. cardiac:
29. EKG:
30. R/O:
31. UGI:
32. Dx:
33. OTC:
34. p.r.n.:
35. p.c.:
36. hs:
37. tx:
38. Why might this patient have thought he was having an MI when he went into the ER?
Transcribed Image Text:C. Notes from T. Ayers, ER Physician Assistant, to pt's PCP, Dr. R. Bailey Pt was evaluated in ER with c/o chest tightness, SOB and dyspepsia. Pt was concerned that he was having an MI. P and BP were WNL Lab test for cardiac enzymes and EKG to R/O MI was negative. UGI X-rays Dx a hiatal hernia. Instructed Pt to take OTC antacids p.r.n. 1 hour p.c. and at hs. Please follow up with pt for further tx. 18. ER: 19. PCP: 20. c/o: 21. SOB: 22. dyspepsia: 23. MI 24. P 25, BP: 26.WNL: 27. lab: 28. cardiac: 29. EKG: 30. R/O: 31. UGI: 32. Dx: 33. OTC: 34. p.r.n.: 35. p.c.: 36. hs: 37. tx: 38. Why might this patient have thought he was having an MI when he went into the ER?
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