Medical Documents Essay

This is a SOAP document which is used to determine used to determine the competency of potential physician’s assistants to read and understand medical documents containing acronyms and medical abbreviations. The document contains a fictional patient who suffers from an ailment that the recruit would have to decipher from the patient’s history and symptoms. The recruit would also have to determine the meanings of medical abbreviations determining the correct meaning of the acronym. The fictional patient will be given a full medical and family history and an ailment from the urinary system. All symptoms exhibited will be tabulated and potential tests done. It is up to the potential physician’s assistant to determine what the potential diagnosis is, and what is to be done about it. This will determine how much additional training the physician’s assistants need to be effective.

History (subjective)

CC: Burning pain while peeing.

HPI: A 26 year old African woman, presents with a burning pain while urinating over the last one week. She feels the urge to urinate even immediately after visiting the ladies. Apart from the pain and urinary urgency, she feels tenderness above the pubic area. She has no boyfriend and has not engaged in sexual intercourse for the past six months.

PMH: She denies previous illness, and has had no previous surgeries apart from one C-section at nineteen. Primi gravid, G1P1 LC1. DH; She is currently on the COCP (“oxford medical dictionary”, 2007) and takes vitamin pills daily. She has no drug Al and is up to date on her immunization schedule. Cannot recall the occasion of her last physical/pap smear, BSE, K 4/28.

SH: She imbibes the occasional alcoholic beverage, and has taken marijuana on occasion. She lives with her mother and her six year old son. She works as a bartender six days a week, and is a part time college student.  The toilet facilities at the bar where she works are less than hygienic, and the work environment is very hectic.

FH: Father Deceased, (HIV-related complications), Mother 45, no known health problems, Son, 6, ADHD. Parents are discordant couple, or mother could be elite carrier. No history of cancer or stroke in family. One uncle is mentally ill (MPD).

RoS:  Due to fear of what she may be suffering from, patient has lost her appetite and is not sleeping well. As a result, she looks haggard and ill-looking. Due to the discomfort in her vaginal area, she walks slowly with a strange gait. Intake of fluids has reduced due to fear of painful micturition, leading to dehydration. There is no swelling of ankles, no coughing or sneezing. Urine is cloudy and sometimes bloody. Skin is dry and rough, but not peeling of flaking. There are no chest pains or muscle aches although the suprapubic region is tender.

PHYSICAL EXAM (objective)

Vitals: 120/80, 75 reg, 980 (36.7), resp 12, weight 167lbs. height 70 inches. (“standardized patient program”, 2007)

General:  Reasonably intelligent, fit, attractive female, negligently dressed and with fearful demeanor.

Head: atraumatic, normocephalic, EOMI, PERLA, mucosae moist.

Neck: supple with no masses/tenderness. Swollen lymph nodes. Thyroid normal.

Chest:  normal appearance of chest; lungs clear to auscultation, vesicular breath sounds, no rhales, rhonchi or rubs. PMI not displaced, RRR 75 bpm, normal S1, S2, no murmurs.

Abdomen: tenderness in UGT area.

Extremities: no ankle oedema, feet and hands normal.

CNS: Alert, speech not slurred, abnormal gait due to tenderness in nether regions, appropriate affect and speech.

Cranial nerves II-XII intact. Fundi normal.

Genital exam: pus cells, red cells and organisms seen on microscopic exam. Urine cloudy with unpleasant odour, dysuria.

Summary of findings

Patient is of normal weight, in good general health, has no history of chronic disease, lucid and intelligent. She is exhibiting painful micturition, as well as urinary urgency. Her LUTS include tenderness in the suprapubic area and ME exhibits pus cells as well as red cells in the urine, which is cloudy, and sometimes hematuria. (Mcleod ,1986, pg. 395).

Diagnostic Work-Up.

Urinalysis

FBC

Blood sugar.

Acronyms that can be misinterpreted include FH which in addition to family history, may also stand for fundal height. However, in the context in which it is used, it is clear which abbreviation is being referred to.

Management Plan.

Advice the patient on the importance of good hygiene.

Follow- up on blood work and urinalysis.

Administer appropriate prescription.