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«Medical Record Library Chapter 3 Medical Record 3-1 FOLLOW-UP NOTE The patient is a 46-year-old white female with a diagnosis of stage IIB (T2, N1, ...»

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Stedman’s Medical Terminology

Steps to Success in Medical Language

Medical Record Library

Chapter 3

Medical Record 3-1


The patient is a 46-year-old white female with a diagnosis of stage IIB (T2, N1, M0)

large cell carcinoma of the right upper lobe status post right upper lobectomy. She

received a course of postoperative radiation therapy directed to the mediastinum,

receiving a total dose of 5,040 rads with completion of treatment on April 13, 20xx. She was last seen in followup on July 28, 20xx, and returns today for a routine 4-month follow-up. She was recently seen by Dr. Smith.

Chest x-ray was obtained on October 14, 20xx. This was compared with previous one of June 15, 20xx. The left lung remains completely clear. There is a slight increase in interstitial markings around the left hilar area. This is within the prior radiation therapy field. This most likely represents radiation-induced scarring.

She is feeling well overall. Her appetite has been good. She has occasional chest discomfort with occasional cough. She denies any pain referable to the thoracotomy site.

She has no hemoptysis. She denies any bone pain. She has no bowel or bladder complaints. She remains active and is feeling well overall.

PHYSICAL EXAMINATION: Blood pressure is 110/74, pulse 72, and respirations 20.

Weight is 153 pounds, up 4-1/2 pounds since last being seen. Today on HEENT examination, extraocular movements are intact. Pupils are equal, round, and reactive to light and accommodation. Normocephalic. She has no palpable cervical, supraclavicular, axillary, or inguinal lymphadenopathy. The heart beats with a regular rate and rhythm.

Lungs are clear to auscultation and percussion. The right thoracotomy incisional site is well healed. There are no palpable abnormalities. The abdomen is soft and nontender, with no mass or organomegaly. Extremities reveal no edema, cyanosis, or clubbing.

ASSESSMENT: We are pleased with the patient’s condition with no evidence of recurrent, residual, or metastatic disease.

PLAN: She is scheduled to see Dr. Smith in January. We have asked her to return for routine follow-up in 6 months. We have requested a chest x-ray at that time. We will keep you informed of her progress.

Medical Record 3-2


© 2011 Wolters Kluwer Health/Lippincott Williams & Wilkins Stedman’s Medical Terminology Steps to Success in Medical Language


PREOPERATIVE DIAGNOSIS: Solitary pulmonary nodule with bronchogenic carcinoma.

POSTOPERATIVE DIAGNOSIS: Solitary pulmonary nodule with bronchogenic carcinoma.


1. Bronchoscopy.

2. Right thoracotomy.

3. Lateral segmentectomy of right middle lobe, followed by completion of right middle lobectomy.

4. Mediastinal lymphadenectomy.

ANESTHESIA: General endotracheal.

DESCRIPTION OF PROCEDURE: After successful induction of general endotracheal anesthesia, the patient was placed in the supine position and bronchoscopy performed via the endotracheal tube. The left upper lingular lobes, right upper and lower lobes were unremarkable. The bronchoscopy tube was well situated within the left main stem bronchus. Then the patient was positioned, prepped, and draped in the usual sterile fashion and underwent a right lateral thoracotomy.

The thorax was entered. The pleura was unremarkable. The lung was explored. There was a nodule present within the lateral segment of the right middle lobe. The dissection was carried down to the artery, which was doubly tied proximally and distally and divided, and this segment was then stapled off and sent for frozen section. The frozen section was consistent with a squamous cell carcinoma. Consequently the lobectomy was completed, and lymph nodes were harvested.

A chest tube was brought out through a separate stab incision. The intercostal membranes were closed. The muscles, subcutaneous tissue, and the skin were closed. A Dermabond dressing was applied. The chest tube was attached to drainage. The sponge, needle, and lap counts were correct x3, and the patient was taken to the recovery room in stable condition.

Ch 3 Medical Record Review #1



1. Clostridium difficile colitis, recurrent.

2. Dehydration.

–  –  –

3. Cancer of the stomach with metastases to peripancreatic lymph node.

HOSPITAL COURSE: The patient is a 72-year-old gentleman admitted through the emergency room. The patient was just in my office prior to admission for IV hydration because of dehydration, generalized weakness, and a syncopal episode at home. He had been discharged from the hospital about a week ago because of recurrent Clostridium difficile infection. He was first found to have a C. difficile infection in March 20XX and was hospitalized, probably after IV antibiotic use with Invanz, which he received during stomach surgery. He was treated with vancomycin and got better.

About two weeks ago, he received a few days of p.o. vancomycin during a hospitalization and was sent home on a 10-day course of Flagyl. He stated that he never truly got 100% well. He started having the frequent diarrheal stools just prior to admission and became very, very weak. He was dehydrated. He received IV fluid, and I restarted him on p.o.

vancomycin immediately. Dr. Peters was consulted, who felt that the patient should stay on vancomycin for 6 to 8 weeks, with dosage taper.

The patient slowly improved and is now anxious to go home. Having received full benefit of hospitalization, it was felt justified to release him on p.o. vancomycin 250 mg 4 times a day for 10 days and then change to 250 mg twice a day for about a month. I have also asked him to resume traditional Chinese herbal remedy, which I have prepared for him specifically, and also to stop Nexium and take a probiotic on a daily basis, and hopefully, with all these changes, he will be able to prevent another Clostridium difficile infection.

In a week to two weeks, if he feels better, we may consider radiation treatment directed toward the peripancreatic lymph node. It may be hard to continue chemotherapy.

Chapter 4 Medical Record 4-1


SUBJECTIVE: This is an emergency visit for a 20-year-old man who accidentally knocked over a pot of boiling water onto his left leg and foot. He is complaining of extreme pain. He stated that he used some aloe on his leg and foot immediately after the accident occurred. Because of the continued pain, he presented to the office to ensure that the burn was nothing more than superficial.

OBJECTIVE: BP 130/76; P 98; T 98.6°F. This is a well-developed, well-nourished young man who presents with a reddened and blistered area on the anterior aspect of his left leg and on the dorsum of the left foot. Some of the blisters have broken and are weeping.

–  –  –

ASSESSMENT: Superficial and partial-thickness burns on the anterior aspect of the left lower leg and dorsum of the left foot.

PLAN: The patient was prescribed acetaminophen with codeine to take one every 4 hours p.r.n. for pain. The area was treated with silver sulfadiazine for possible infection.

The patient was instructed to change the dressing daily and was given supplies to do this.

He was instructed to return in 3 days for a recheck.

Medical Record 4-2


SUBJECTIVE: Nursing assistant noticed an area of broken skin on the right heel of the patient.

OBJECTIVE: This 83-year-old female is cachetic from her long-standing Alzheimer’s disease and refusal to take in sufficient nutrition. She is fed by way of nasogastric tube, which she has been known to pull out. Her weight is 110 pounds. Her skin turgor is poor, and the area of broken skin is erythematous and shiny. Some areas of blackness are noted around the edges.

ASSESSMENT: C&S will be performed on a swab from the area in question. It appears to be a stage II starting into stage III decubitus ulcer. At this point, it has not developed to the point where there is any necrotic tissue that needs to be débrided.

PLAN: The patient will be turned on a more frequent basis. The timeframe will be increased from every 2 hours to every hour. Her tube feedings will have increased calories and protein to promote wound healing. The wound will be cleaned with normal saline. If the C&S comes back positive, the patient will be started on antibiotics. The heel area will be placed on an egg crate mattress when she is in the supine position.

Ch 4 Medical Record Review #1 CONSULTATION: Bruise-Like Lesions on Legs

Dear Dr. Garcia:

Your patient was seen in my Dermatology Clinic on 11/19/20XX for a skin check. Most specifically, she was concerned about bruise-like lesions on the legs. These have been present for about a year, they were worse with prolonged walking and activity, but were otherwise asymptomatic. She has a history of osteoarthritis of the knees, and has had intra-articular steroid injections, but the bruise-like lesions began before the injections were performed.

© 2011 Wolters Kluwer Health/Lippincott Williams & Wilkins Stedman’s Medical Terminology Steps to Success in Medical Language On clinical exam, there are blanchable, red to violaceous patches on both medial knees.

There is no scale, no atrophy, and no induration. The lesions are peculiar and difficult to fully characterize. They do appear benign at this time, but I have asked her to continue to observe the lesions. I would also like to have the patient call if the problem does worsen or becomes symptomatic.

Thank you for allowing me to participate in the care of her. If I can answer any specific questions, please feel free contact me at any time.

Sincerely, Dr. Andre Horowitz Ch 4 Medical Record Review #2 CHART NOTE: Recurrent Nevus PATIENT: Allice Wonder DATE: 1/25/ 20XX SUBJECTIVE: Recurrence of growth on the patient’s right arm. The patient was in my office four months ago. At that time, three changing moles were excised: one on the right arm, marked A; one on the right hand; and one on the left side of the chest. The one marked A was read by the pathologist as a pigmented compound nevus with mild atypical melanocytic hyperplasia, margins free and adequate.

OBJECTIVE: Very small pigmented lesion, approximately 2-3 mm in diameter in the same area.

ASSESSMENT: Atypical and dysplastic nevus, possible recurrence.

PLAN: The patient was fully counseled regarding healing with scarring and keloid development; however, due to the nature of the nevus and recurrence, we will need to remove a minimum of 4-5 mm of normal surrounding skin. The patient was fully accepting of the possibility of scarring, keloid formation, and/or the recurrence. After a sterile prep, the area surrounding the nevus was anesthetized with Xylocaine 2% with epinephrine. The tumor was excised with a large area surrounding the brown pigment, approximately 4-5 mm. The resulting defect was closed using 4-0 Vicryl x2 and 4-0 Prolene in interrupted sutures. The specimen was marked C-1 and sent to Pathology for evaluation. The patient is instructed to keep the site clean and dry and return in 10 days for suture removal. A handout covering aftercare was given to the patient and discussed.

–  –  –

Patient presented to the clinic today with having had a BM this morning in which he noticed a large amount of bright red blood in the toilet. He denied any pain with the BM.

This was the first time this has happened. No associated nausea and vomiting or diarrhea.

He did mention that he has been constipated for the past week or so. He stated he had small, hard stools that he had to strain to pass a couple of times during the last week. The patient has no history of peptic ulcers or gastrointestinal cancer.

OBJECTIVE: Wt. 195, BP 160/88, P 88. The patient is a well-developed, wellnourished male in no acute distress. Examination of the rectal area reveals a small tear in the rectal mucosa.

MEDICATIONS: Ibuprofen p.r.n.; metoprolol 50 mg b.i.d.

ASSESSMENT: The patient has a small anal fissure. This is most likely caused from several incidences of constipation with associated straining.

PLAN: The patient was instructed to increase the amount of fiber in his diet as well as to use an OTC laxative to increase the frequency of his BM and to soften the stool. He was advised to not strain as this would increase the likelihood that any hard stools that are passed will worsen the tear. This should resolve on its own. The patient is instructed to call the clinic should he continue to have issues.

Medical Record 5-2 GERD

–  –  –

Mr. Edwards came to the clinic today with complaints of heartburn and postprandial regurgitation. He states that these symptoms increase in severity soon after he lies down in his recliner after eating to watch TV. He is on no regular medications except that he does take occasional Maalox when his symptoms are “too much to handle.” These symptoms have only started to bother him recently, within the past month or so. He also complains of some flatus.

–  –  –

OBJECTIVE: This is an obese, well-developed male. Currently, he is in no distress.

Weight today is 295. This is an increase since his last visit 6 months ago when he weighed 256. He has just recently lost his job and has stopped going to the gym because he had let his membership lapse.

ASSESSMENT: GERD with increase in weight and decreased activity.

PLAN: Start proton pump inhibitor b.i.d. Encourage patient to try to get back into routine of exercise. Discussed dietary guidelines to decrease fatty food intake. Discussed the need to abstain from coffee, tea, chocolate, and activities such as lying down or reclining immediately or soon after eating. The patient was encouraged to raise the head of his bed about 2 inches. If symptoms persist, Mr. Edwards is to return to clinic. More aggressive evaluation with endoscopy will then be scheduled.

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