Hs111 Unit 6 Essay

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Section 4: Identifying the mistakes and listing the correct terms. Main Street Hospital and Medical Center 6000 North Tree Street - Branch, Pennsylvania 12345 – (555) 123-4567 -------------------------------------------------------------------------------------------------------------------------------------------------- PATIENT NAME: Sam Samuel MEDICAL RECORD: 5555555 DATE OF DEATH: 04/04/1954 DATE OF ADMISSION: 07/31/2013 PROGRESS NOTE CHIEF COMPLAINT: Severe lower abdominal pain and the inability to void for the past 12 hours. PRESENT ILLNESS: Sam Samuel is a 59-year-old Asian-American man who came into the emergency department at 3 a.m. stating that he was in great pain and could not urinate. He had not been seen by a physician for several years but claimed to be in good health except for “a little high blood pressure.” The patient reports urinary frequency, noicturia x2, hesitancy, intermittency, disuria, and diminished force and caliber of the bladder system. In addition, he complained of intermittent pain in the right posterior lumbar area, radiating to the right flank. He also has post-void dribbling and the sensation of not having completely emptied the bladder. Earlier today, he had hematuria at the end of urination and several bouts of N&D. MEDICATION ALLERGIES: None CURRENT MEDICATIONS: Benadryl 25 mg. dailys, at bedtime. PHYSICAL EXAM: Temperature 98.6® F. Blood pressure 140/90. Pulse 98. Respirations 24. Palpation of the abdomen shows a suprapubic mass approximately three fingerbreadths below the umbilicus, dull to percussion, and slightly tender. IMPRESSION: Renal Pelvis distention caused by urinary outlet obstruction, probably from benign prostatic hyperplasia. PLAN: Indwelling Foley catheter for relief of urinary obstruction. Imaging to include a CAT scan, kidney ultrasound and IVR. Urinary consult.

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