Progress Report

Categories: Progress

In this Assignment you will proofread the Progress Report listed below. Next, you will identify the 10 mistakes that are listed in the report. The mistakes could be misspellings, incorrect abbreviations, or misuse of a medical term. Please list them in the chart below under the heading “Medical Terminology Error.” After you have listed the errors, you will need to identify the correct term or abbreviation. Please list them in the chart below under the heading “Correct Term.” At the end of the project be sure to list all applicable references and cite them in APA format.

Main Street Hospital and Medical Center
6000 North Tree Street – Branch, Pennsylvania 12345 – (555) 123-4567

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PATIENT NAME: Susan SunshineMEDICAL RECORD:5555555

DATE OF DEATH:04/04/1954DATE OF ADMISSION:07/31/2013

PROGRESS NOTE
CHIEF COMPLAINT: Severe lower abdominal pain and the inability to void for the past 12 hours.

PRESENT ILLNESS: Sam Samuel is a 75-year-old Asian-American man who came into the emergency department at 3 am stating that he was in great pain and could not urinate.

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He had not been seen by a physician for several years but claimed to be in good health except for “a little high blood pressure.” The patient reports urinary frequency, noicturia x2, hesitancy, intermittency, disuria, and diminished force and caliber of the bladder system. In addition, he complained of intermittent pain in the right posterior lumbar area, radiating to the right flank. He also has post-void dribbling and the sensation of not having completely emptied the bladder. Earlier today, he had hematuria at the end of urination and several bouts of N&D.

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MEDICATION ALLERGIES: None

CURRENT MEDICATIONS: Benadryl 25 mg. dailys, at bedtime.

PHYSICAL EXAM: Temperature 98.6® F. Blood pressure 140/90. Pulse 98. Respirations 24. Palpation of the abdomen shows a suprapubic mass approximately three fingerbreadths below the umbilicus, dull to percussion, and slightly tender.

IMPRESSION: Renal Pelvis distention caused by urinary outlet obstruction, probably from benign prostatic hyperplasia.

PLAN: Indwelling Foley catheter for relief of urinary obstruction. Imaging to include a CAT scan, kidney ultrasound and IVR. Urinary consult. Labs to include white blood count, hemoglobin, hematocrit, blood urea nitrogen (BUA) and urinalnysis.

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Progress Report. (2016, Apr 01). Retrieved from https://studymoose.com/progress-report-2-essay

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