Week 5 ME2220X Medical Records
Tracye Braden
UMA
Guerda Louissaint
ME2220X
02/25/2014
In a document (MS Word or WordPad) do the assignment based on the following directions and medical
records. Save your file and attach the file to the assignment Dropbox for grading.
Review the following medical records.
Provide a definition for each of the underlined medical terms.
Identify one misspelled word in each medical record, noting proper spelling.
Define one additional medical term within each record that you are not familiar with.
MEDICAL RECORD 1
University Hospital and MedicalCenter
4700 North Main Street Wellness, Arizona 54321 (987) 555-3210
PATIENT NAME: William Graves CASE NUMBER: 20066-OPH
DATE OF BIRTH: 06/27/xx DATE: 04/05/xx
PROGRESS NOTE
SUBJECTIVE: Mr. Graves is a 66-year-old white man here today for his annualophthalmology
examination. He has no current complaints. He has a family history of glaucoma in his brother.
He has a history of hypertension and type 2 diabetes mellitus. A pterygium was removed from
his right eye 5 years ago.
CURRENT MEDICATIONS: Glyburide 5 mg bid and Lopressor 50 mg bid.
ALLERGIES: None
OBJECTIVE
Visual Acuities: Aided: OD 2/25-2 OS 20/30-1 OU 20/25
Unaided: OD 20/100 OS 20/80-1 OU 20/80
Externals: 2-mm blepharoptosis OD. PERLA. EOMI.
Ophthalmoscopic: Lens: OS showed early cortical spokes
Disk: margins normal
Cup-to-disk ratio: 0.2 OU
Fundus: Within normal limits including DVM
Refraction: OD-1.00-0.50 x 90 20/20, OS-1.25-0.25 x 90 20/20
Tonometry: 14 mm Hg OD, 13 mm Hg OS.
ASSESSMENT: Patient has compoundmyopic astigmatismand presbyopia with mild diabetic retinopathy
and grade II hypertension. He also shows an early cataract in the left eye.
PLAN: Provide prescription for corrective lenses. See patient for follow up visit in six months to
reevaluate diabetic retinopathy and cataract. Counseled patient to report any sudden changes in vision.
Visual Field: Full
Part 2.
Dr. Milli Bentley, MD
MB/mcm
MEDICAL RECORD 2
University Hospital and MedicalCenter
4700 North Main Street Wellness, Arizona 54321 (987) 555-3210
PATIENT NAME: Jimmy Tohe CASE NUMBER: 99665-AUD
DATE OF BIRTH: 03/04/xx DATE: 09/04/xx
PROGRESS NOTE
SUBJECTIVE DATE: Jimmy Tohe is a 62-year-old American Indian man who appears younger than his
stated age. He was brought into the ENT clinic by his daughter, who states that he is unable to hear
what is being said to him by family members. She states that this problem has existed for at least 30
years but that it appears to be getting markedly worse. The patient states he had several episodes of ear
infections as a child and young adult. He denies any tinnitus or vertigo.
OBJECTIVE DATA: Temperature, 99.4. Pulse, 72. Respirations, 2 0. Blood pressure, 136/76.
Weight, 162 pounds. Patient ambulates without difficulty. Alert and oriented x 3. Otoscopy
reveals scarring of the timpanic membranes bilaterally. Auditory canals appear normal bilaterally.
Patient states he is allergic to Demerol.
ASSESSMENT
1. Severe loss of hearing bilaterally, probably caused by otitis media as a child.
2. Recent exacerbation of hearing loss most likely attributable to presbycusis.
PLAN: Patient referred to audiologist for complete audiometry workup.
Bridey Mckeegan, MD
BM/mcm
Part 2.