You are . . . a Certified Medical Assistant working with Susan Lee, MD, a primary care physician at Fulwood Medical Center. Your patient is . . . Mrs. Sandra Jacobs, a 46-year-old mother of four. Your task is to document her care. Documentation Mrs. Sandra Jacobs, a 46-year-old mother of four, presents in Dr. Susan Lee’s primary care clinic with episodes of crampy pain in her right upper quadrant associated with nausea and vomiting. The pain often occurs after eating fast food. She has not noticed a fever or jaundice. Physical examination reveals an obese white woman with a positive Murphy sign. Her BP is 170/90. A provisional diagnosis of gallstones has been made. She has been referred for an ultrasound examination, and an appointment has been made to see Dr. Stewart Walsh in the Surgery Department. I explained to her the etiology of her gallstones and the need for surgical removal of the stones, and I discussed with her a low-fat, 1500-calorie diet sheet. Luisa Guitterez, CMA. 10/12/12, 1430 hrs. In which quadrant is Mrs. Jacobs having pain? The fact that she does not have jaundice rules out a disorder of the? What is a positive Murphy sign? What additional diagnostic procedure is she scheduled for?
You are
. . . a Certified Medical Assistant working with Susan Lee, MD, a primary care physician at
Fulwood Medical Center.
Your patient is
. . . Mrs. Sandra Jacobs, a 46-year-old mother of four. Your task is to document her care.
Documentation
Mrs. Sandra Jacobs, a 46-year-old mother of four, presents in Dr. Susan Lee’s primary care clinic with episodes of crampy pain in her right upper quadrant associated with nausea and vomiting. The pain often occurs after eating fast food. She has not noticed a fever or jaundice.
Physical examination reveals an obese white woman with a positive Murphy sign. Her BP is 170/90. A provisional diagnosis of gallstones has been made. She has been referred for an ultrasound examination, and an appointment has been made to see Dr. Stewart Walsh in the Surgery Department.
I explained to her the etiology of her gallstones and the need for surgical removal of the
stones, and I discussed with her a low-fat, 1500-calorie diet sheet. Luisa Guitterez, CMA. 10/12/12, 1430 hrs.
In which quadrant is Mrs. Jacobs having pain? The fact that she does not have jaundice rules out a disorder of the? What is a positive Murphy sign? What additional diagnostic procedure is she scheduled for?
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