Chapter 1: Case Study
- Why is it important that the admitting doctor record information about the patient’s heart, lungs, and other body systems when the pain is in the patient’s abdomen?
It is important for the admitting doctor to record information about the patient’s heart, lungs, and other body systems because abdominal pain can be a symptom of a wide range of medical conditions that may affect other body systems. By performing a thorough physical examination and documenting the findings, the doctor can rule out other potential causes of the patient’s symptoms and make an accurate diagnosis. Additionally, assessing the patient’s heart and lung function can help determine if there are any underlying cardiovascular or respiratory issues that may complicate the patient’s treatment or surgery.
- Find out the meaning of HEENT. How can you find out what the abbreviations in this case study are?
One could consult a website or medical reference book to learn the meaning of the abbreviation “HEENT”. The abbreviation HEENT is for Head, Eyes and Ears. It can be used to refer to the physical exam of these areas.
These are just a few of the abbreviations that were used in this case report:
- Historical History of Current Illness
- PMH: The Past Medical History
- PSH: Past Surgery History
- NPO: Nothing by Mouth
- RRR: Regular Rate and Rhythm (referring to the patient’s heart rhythm)
- m/g/r – Murmurs, Gallops or Rubs refer to abnormal sounds in the heart
- Using what you’ve learned about word parts, describe the types of surgeries listed in the patient’s past surgical history.
The patient’s past surgical history includes tonsillectomy and adenoidectomy, as well as umbilical hernia repair. Tonsillectomy is the procedure to remove the tonsils. These are found in the back part of the throat. They may need to be removed because of recurrent infections, breathing problems or other reasons. Recurrent infection or obstruction may cause the need to remove the tonsils. Adenoidectomy is the surgical procedure that involves the removal and resection of the adenoids. Umbilical hernia treatment is performed to repair a hernia located at the abdomen button. The abdominal tissue and organs protrude into the weakening area.
- The extremities are described as “No clubbing, cyanosis, or edema.” Edema is explained in this chapter. Find out what these terms are.
Clubbing can be described as a condition in which the tips of fingers and toes are enlarged, rounded and the nails curve downward. It could be an indication of a more serious medical condition such as heart disease or lung disease.
Cyanosis can be described as a blueish-bluish coloration in skin or mucous membranes due to oxygen deficiency. It could be an indication of a underlying medical condition such as a respiratory or cardiovascular problem.