(SOLVED) Practice Sheet 5 W-MT (written 5)

Discipline: Nursing

Type of Paper: Essay (any type)

Academic Level: Undergrad. (yrs 3-4)

Paper Format: APA

Pages: 1 Words: 254

Question

Practice Sheet 5 W-MT (written 5)

Convert the below dictated lines into Preoperative History and Physical Report transcription with appropriate format of chart note including headings and all the rules of chart note transcription

the sixty seven year old gentleman underwent ultrasound guided needle biopsy of the prostate during the trans rectal ultrasound a positive bladder mass was noted


he is now to undergo a cystoscopy for confirmation


current medications includes cardura four milligram by mouth every hour multiple vitamins Aspirin, lipitor


  • allergies plant pollen

  • past medical history hypertension

  • past surgery transectomy and removal of lymphoma

  • physical examination he appears well alert and oriented

  • vital signs blood pressure one sixty seven over seventy nine pulse seventy respiration eighteen

  • lungs clear

  • heart rhythm is regular without murmur

  • abdomen soft without masses or tenderness

  • groin is normal.

  • extremities no peripheral edema

  • digital rectal exam(DRE) the prostate was smooth with benign consistency

  • diagnosis possible bladder tumor


EXPERT SOLUTION (PREVIEW)


Converting the given details into a preoperative history and physical report,


  • step 1


Patient Name :


Date :


Age : 67


Sex : Male


MR# ; ( Insert medical record number )


Chief Complaints:


- Positive bladder mass noted during ultrasound guided needle biopsy of the prostate




History of Present Illness:


- The patient underwent ultrasound guided needle biopsy of the prostate, during which a positive bladder


mass was found.


- He is now scheduled to undergo a cystoscopy for confirmation




Medications:


- Cardura 4mg, Orally every hour.


- Multiple Vitamins


- Aspirin


- Lipitor




Allergies:


- Plant pollen




Past Medical History:


- Hypertension




Past Surgical History:


- Transectomy and removal of lymphoma




Physical Diagnosis:


- General: The patient appears well, alert, and oriented.


- Vital signs: Blood pressure of 167/79 mmhg, pulse of 70 beats per minute, and respiratory rate of 18


breaths per minute


- Lungs: Clear


- Heart: Rhythm is regular without murmur


- Abdomen: Soft, without masses or tenderness


- Groin: Normal


- Extremities: No peripheral edema


- Digital Rectal Screening: The Prostate was smooth with a benign consistency




Diagnosis:


- Possible bladder tumor


Signature,


( insert physician name )


( insert physician signature)