I am having trouble finding all of the mistakes in this section.
My current errors found are:
Patent |
nasuseated |
breathe |
Darelen |
Penisyllin |
Aarythmia |
Myelocardial |
Pulse 110. |
consult |
q 4 hours |
q 6 hours |
sub q |
The current corrections are:
Patient |
nauseated |
breath |
Darlene |
Penicillin |
Arrhythmia |
Myocardial |
Pulse 110, |
consults |
q4h |
q6h |
Sub-Q |
Section 4: Identifying the mistakes and the correct terms.
Main Street Hospital and Medical Center
6000 North Tree Street – Branch, Pennsylvania 12345 – (555) 123-4567
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PATENT NAME: Darlene Denton MEDICAL RECORD: 5555555
DATE OF BIRTH: 08/06/1952 DATE OF ADMISSION: 01/15/2015
PROGRESS NOTECHIEF COMPLAINT: Severe pain between the shoulder blades, shortness of breathe, nausea for the past 3 hours. PRESENT ILLNESS: Darelen Denton is a 62-year-old woman who presented to the emergency department via ambulance. In transport, patient received O2 at 4 liters via nasal cannula, baseline EKG, Normal Saline IV started in left hand, 325 mg aspirin by mouth (po). Patient complained she was short of breath and experiencing severe pain between her shoulder blades. She stated that she has been feeling nasuseated for the past 3 hours. She states she has a history of stable angina and is currently taking medication as needed. She states she did not take the nitroglycerin because she was not experiencing chest pain, just back pain. She states that her last check-up with the Pulmonologist showed that her EKG did not show any changes since her last visit. She denies episodes of syncope. The patient does report that she tripped over something on the floor, which resulted in her falling and hitting her back on a large table. In addition, she states that her heart rate has been ranging from 130/ 90 to 140/92. Patient states her Primary care physician placed her on blood pressure medication 2 months ago due to the increase. ALLERGIES: Penisyllin, IVP dye, mold, pollen CURRENT MEDICATIONS: Lovastatin 20 mg po per day, Enalapril 20 mg po bid, Nitroglycerin 0.4 mg sub q prn for chest pain. PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia noted. No edema noted in extremities. Patient skin is cool to touch, slightly clammy. EEG shows prolonged QRS wave, with ischemic ST changes and PVCs. Chest radiograph clear. IMPRESSION: Aarythmia, CPK and Troponin levels were elevated indicative of Myelocardial infarction. The EKG revealed a high heart rate and complete block. PLAN: Cardiology consult. Nitroglycerin 0.4 mcg given sublingual. Oxygen started at 4 liters via nasal cannula, Morphine sulfate 4 mg given IV for pain. Heparin (anticoagulant) drip started IM. Immediate transfer to Cardiac Cath Lab for PCTA. CPK and Troponin q 4 hours, H & H and PTT q 6 hours, Heparin adjusted per scale.