Medical Record Office Question & Answer Guide (With Explanation)

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to medical record office and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves medical record office. A strong answer should include explanation, application, and examples.

Original Question

MEDICAL RECORD OFFICE – NEW Dr. John Smith SEX: MALE Age: 16 DOS: 1/1/20XX CC: Pain in right shoulder Impression: probable SLAP lesion of right shoulder Plan: MRI arthrogram of the shoulder and follow up again after the scan. Patient is a 16-year-old boy who says that about 3 weeks ago he injured his shoulder while playing football. He says he fell onto the shoulder and ever since then he has noted popping sensations in certain positions of the arm and these are quite painful. He says he is having difficulty throwing with that arm. He also notes that he has never had any history of dislocation of the shoulder and does not feel any symptoms suggestive of instability of the shoulder. No specific treatment for his pain. He did go to the ER at Hospital where an x-ray was taken and was reassured about his symptoms. He was advised if not better to see Primary Care Physician. Past Medical History: no chronic illnesses. Past Surgical History: no previous operations Allergies: none Medications: none Social History: The patient does not smoke, drink alcohol or use illegal drugs Family History: Hypertension and kidney disease ROS: HEENT, GI, GU, cardiorespiratory, neurological, endocrine and constitutional systems were reviewed, and these are negative. PHYSICAL EXAMINATION: Vital Signs: Pulse: 79; Respirations: 19; Blood pressure: 113/79; Temperature: 98.6 F°; Weight: 170 lbs; Height: 5’6″. GENERAL: He is a well-nourished African-American boy sitting on the couch in no acute distress, well oriented to time, place, and person. HEENT: head is atraumatic and normocephalic. Mucous membranes are moist. NECK: supple and nontender. HEART: S1 and S2. LUNG: clear. ABDOMEN: soft and nontender. Extremity Exam: Right shoulder examination shows that he preserves full range of motion with no signs of impingement. There is palpable popping and clicking when he moves his shoulder, especially when he descends from a fully abducted position. The O’Brien test was uncomfortable, but not particularly painful. Rotator cuff strength appears well-preserved. Instability examination was negative. No neurocirculatory problems identified. Neck exam did not provoke any pain. Alert and Oriented X3, Respiratory has equal breaths. X-Rays: X-ray of the right shoulder, 1 view, taken in the ER was reviewed, possible SLAP lesion of the right shoulder, need MRI for clarification diagnosis. I discussed with patient about his diagnosis. I suggested that he might have a SLAP type lesion of the shoulder which may explain his pain. I suggested an MRI arthrogram of the shoulder to clarify the diagnosis further. He agreed with this and this was requested. He will be seen again in the office after the reports are available. May need to refer on to Orthopedic Specialist after MRI. ASSESSMENT: RT SHOULDER PAIN

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