HS111 Unit 6 Assignment 2

ABC Medical Center

7777 North West Street, Michigan 12345 – (555) 123-4567

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PATIENT NAME: Deana MartensMEDICAL RECORD:8888888

DATE OF BIRTH:3/26/1947DATE OF ADMISSION:1/19/2015

PROGRESS NOTE

HISTORY: Deana Martens is a 67-year-old Caucasian female who was brought to the hospital via an ambulance and subsequently admitted to the hospital on 1/19/2015 for dysphasia, dysphagia, and right hemiparesis. Ms. Martens has history of HTN, and High Cholesterol. Husband states that patient is taking medication daily. No problems have been noted prior to 1 ½ hours ago when she began to show signs of right facial drooping and complained of cephalgia. Husband states the patient was unable to drink her coffee without the liquid spilling down her face. Per the husband, the patient was reaching in the cupboard for a dish, when her right arm started to fall. After sitting at the breakfast table, the patient began to rise, when she fell to the floor, and was unable to stand up without help. She showed a steady decline within minutes developing ataxia, dysphagia, and dysarthria.

OBJECTIVE FINDINGS: Physical examination shows the patient was alert, and oriented x 2. Mild confusion noted to place. Gait was not assessed at this time due to hemiparesis. Grips were unequal. Right pupil was sluggish to respond to light. Right lower extremity was flaccid. Blood pressure was 180/92 mm Hg. Pulse, 78. Respirations, 18. Temperature 98.7. Chest radiograph, Urinalysis, CBC, PTT, Basic Chemistry Panel and ABGs were obtained. ABGs showed low 02 saturation. CT scan showed negative for an intracerebral hemorrhage. A neurology consultation was obtained. Neurologist confirmed the diagnosis of an ischemic stroke after an MRI of the brain demonstrated an ischemic area of the left cerebral cortex caused by a cerebral embolism.

IMPRESSION: Hemiparesis, HTN, Ischemic Stroke

TREATMENT SUMMARY: The patient was given Alteplase 0.9 mg/kg IV infused over 1 hour for first bolus. Continued with 0.81 mg/kg as continuous infusion over 60 minutes. Mannitol was started IV post Alteplase infusion. Patient transferred to ICU. Neuro checks ordered q 2 hrs. On the second hospital day, the patient developed hypotension, N & V. Reglan given IV and normal saline was increased to 150 drops per minute for 2 hours, then titrated down to 75. After 5 hours, patient BP was within normal limits, N & V subsided. Aggrenox started one capsule bid. Third day inpatient stay was unremarkable. Patient was transferred to medical floor. PT/OT, speech therapy ordered. Neuro checks reduced to every 4 hours. No further decline noted. Fourth inpatient stay, patient responding to PT/OT well. Use of walker with one assist. Gait and grip improving. No further neurological deficits noted. Discharge planning started. Rehabilitation facility recommended for continued PT/OT and speech therapy. Family educated on treatment plan, patient transferred to extended care facility for rehabilitation. Continue antiplatelet therapy. Informed patient and family to follow-up with neurologist one week after discharge from rehab.

Good Afternoon, Ms. Sibley, my name is James Pritchard and I am a Registered Nurse here at ABC Medical Center. I know that you are extremely concerned about you mother so I am here to sit and explain to you everything that is going on and what her treatment is going to look like.Your mother came into the hospital by ambulance and was admitted for trouble speaking, difficulty swallowing, and weakness of the right side of her body. It was stated that your mother was unable to drink her coffee without the liquid spilling down her Face. She had also reached in the cupboard for a dish when her right arm started to Fall. After sitting at the breakfast table, she began to rise, when she fell to the floor and was unable to stand up without help. She showed a steady weakness within minutes developing loss of bodily fluids, trouble swallowing, and trouble with talking. A physical exam was conducted and it showed that your mother was alert but showed signs of confusion to where she was. Walking was not assessed due to her right side. Later an MRI was conducted to discover your mother has to bleeding from the brain. Which is causing her weakness, and unsteadiness when she upright.

We did check your mother’s current vital signs. And it was abnormal down the on every level. We have to monitor your mother vital signs, and blood works up. Every two weeks. It a standard practice. To out rule the worst possibilities if any strokes. Medication was given to your mother under our watch to bring down her blood pressure. Mrs. Martens responded well to the medications that were given. And she’s on the road to recovery, and later this week she will be released to go home. However, she will be placed in telemetry until further notice, just be on the safe side. Of her recovery. If you have any questions regarding her treatment plan, we are always a phone call away. If your mother runs of medications. On the top of the medicine bottle. It states how many times you can refill. So there will not be any guess work.

PART 1: Using the information provided in Progress Note above, please complete the following information.

In this Assignment, imagine you are a medical professional working at ABC Medical Center. Your patient is Mrs. Martens. Her daughter, Rae Sibley, has just arrived from Colorado. She is concerned about her mother’s well-being. You will be meeting with the patient’s daughter to update her on what has occurred during her hospital stay, the subsequent transfer to the rehabilitation facility, and a discharge plan.

Use the information from the Progress Note to update Rae Sibley on her mother’s condition. You will be translating the medical information from the report into layman’s terms in order for the patient and patient’s daughter to understand.

Please be sure use complete sentences, proper grammar, and spelling. You can use medical terms, however, you must also use layman’s terminology. Remember, it is your job to explain to the patient’s daughter what has occurred. You may need to use outside sources.

Your explanation to Rae Sibley should be 500 words or more. Cite your reference(s) in APA format at the end of your explanation.

Type your translation of the Progress Note below. Make sure to use layman’s terms in order for Rae to understand what has occurred.

REFERENCE: (APA formatted references are required – list them below)

PART 2 – For this part, you will be completing the crossword puzzle that is below the table. Instead of entering your answers into the crossword puzzle, enter your responses in the table provided.

Across

1.Medical term for “fetus with a small head”

4.Region meaning “inferior to the umbilical”

6.Combining form for “urea, nitrogen”

7.Blood test used to determine the concentrations of oxygen-carrying components in erythrocytes

9.Prefix for “fast or rapid”

10.Medical suffix for “loosening, dissolution, separating”

12.Name of a skin lesion that is characterized as “flat, colored spot”

16.Medical term for “painful or difficult urination”

17.Medical term for “inflammation of the vein”

18.Medical term for “expelling matter from the stomach through the mouth”

20.Medical term for “”

Down

2.Medical term for fingers and toes.

3.Suffix for cell

5.Abbreviation for white blood cell.

8.Another term for urinate or void

11.Abbreviation for abdomen

13.Prefix for “normal or good”

14.Medical term for “pertaining to vision”

15.Prefix for “two”

19.Origin term for “name of person”