Nancy Jackson-Davis Full Medical Record
Nancy Jackson-Davis Full Medical Record
In this course project assignment, you are presented with a full medical chart for one individual patient. An entire medical record can be very lengthy and challenging to navigate. You will see some familiar sections of a medical record that were covered in Modules 02-05, as well as various other notes and details pertaining to this patient.
You will be exploring the medical terminology used in this medical record and will be asked to find information and interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
Download the full medical record for the one patient:
Nancy Jackson-Davis Full Medical Record
Download, complete, and submit the document below. This document contains questions you will answer regarding the medical record for the patient
Patient – Nancy Jackson-Davis
Identify and describe the first diagnosis listed under the Chronic Diagnoses section.
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Which medication was prescribed for Nancy’s diagnosis of gastroesophageal reflux disease?
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Which anatomical organ did Nancy have removed in 1992?
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Which of Nancy’s relatives experienced a condition that could be described as “a protrusion of an abdominal organ”?
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Around 1996, Nancy received a vaccination that will protect which of her digestive organs?
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In Nancy’s physical examination, which two abdominal organs are explicitly noted?
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On her March 6th visit, Nancy received a prescription for a new medication. As noted in her medical chart, what is the medical abbreviation of how many times per day should she take this medication?
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On her April 8 office visit, Nancy reports a new symptom involving blood. Identify the medical term and define it.
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Nancy’s physician notes her pain complaints as “epigastric.” What does this mean? Nancy Jackson-Davis Full Medical Record
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Throughout Nancy’s medical chart, a hernia is mentioned. What type of hernia does she have? Describe where it is and which anatomical structures are involved.
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On April 8, Nancy’s physician orders an imaging procedure. Name and define this procedure.
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On April 8, which lab test is ordered with the order number 1704Q0Y0? If this test were positive, it would mean blood is present in the _____.
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According to Nancy’s imaging report, which of the 3 anatomical regions of the small intestine was explored?
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In Nancy’s imaging report, what does the abbreviation LES stand for?
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Nancy’s imaging report notes a new finding that is not mentioned anywhere else in her medical chart. What is it?
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References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
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You will also likely need to use other course materials or resources to answer all of this assignment’s questions. If you used other references, cite them here:
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*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa Select “References” on the left-hand panel and choose the type of reference you used.
