How to Answer Medical Record Progress Questions (Complete Guide)
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What This Question Is About
This question relates to medical record progress and requires a structured academic response.
How to Approach This Question
Break the problem into smaller parts and analyze each logically.
Key Explanation
This topic involves medical record progress. A strong answer should include explanation, application, and examples.
Original Question
MEDICAL RECORD PROGRESS NOTE AGE: 44 Consulting Physician: Referring Physician: Date: 01/01/20XX PROBLEM LIST 1. 44-year-old with hypertension, with left ventricular hypertrophy. 2. Chest pain. ALLERGIES: Cortisone injections (cause nausea). MEDICATIONS Lisinopril 60 mg q.d. Tylenol p.r.n. Xopenex q.d. INTERVAL HISTORY: The patient has not been seen in this office for 11 months. He presented to the emergency room two weeks ago with sustained substernal chest tightness. This lasted for 10 hours. EKG and troponin were negative, and it was felt that this was bronchospasm. Subsequently, he has been given Xopenex with temporary improvement in his symptoms, however it recurs return promptly. He is to follow up with his doctor. He evidently underwent pulmonary function tests. The report is not available. He relates there was evidence of early obstruction of airways. His blood pressure control has been good. Lipid status is not known. Additionally, he notes he becomes lightheaded when getting up from a lying position. PHYSICAL EXAMINATION VITAL SIGNS: Weight 279-1/2 lbs (283 lbs last year), BP 118/68 in the left arm, pulse 83 and regular. Respiratory rate of 22, oxygen saturation 97% on room air. CONSTITUTIONAL: In no acute distress. HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis. RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour. CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, 2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial dorsalis pedis pulses intact. No leg swelling. GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly. SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis. NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal. LABORATORY AND TESTS EKG (12/15/20XX) shows: 1. Borderline right axis shift, otherwise unremarkable. Labs (12/15/20XX) show: 1. Troponin < 0.04. 2. CRC normal with a hemoglobin of 16.6 grams percent. 3. GFR >60. 4. Otherwise unremarkable. Echocardiogram (12/15/20XX) shows: 1. Concentric left ventricular hypertrophy. 2. Slight borderline dilatation of the left atrium. 3. There is questionable right ventricular hypertrophy. Note: Pulmonary artery systolic pressure could not be measured in the absence of tricuspid or pulmonic insufficiency. ASSESSMENT 1. Chest pain. 2. Hypertension 3. Cardiomegaly (Left ventricular hypertrophy). 4. Possible reactive airways disease. PLAN 1. Followup with doctor. 2. Will obtain results of pulmonary function test. 3. He needs a stress echocardiogram and fasting lipids.
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