In this course project assignment, you are presented with treatment notes for two different patients. Treatment Notes often include medication orders, medication administration, and documentation of procedures, such as physical therapy, respiratory therapy, nutrition counseling, and radiation therapy. These notes include details regarding the type, length, and necessity of treatment. Treatment notes are important to track the execution of the patient’s treatment plan and monitor progression of his or her health outcomes.
You will be exploring the medical terminology used in these test results and will be asked to interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
- Download the treatment notes for the two patients:
Michelle Gibbler Treatment Notes
Todd Anderson Treatment Notes - Download, complete, and submit the document below. This document contains questions you will answer regarding the treatment notes for each patient.
Module 05 Course Project Assignment Template
PATIENT
MichelleGibbler
DOB 05/16/1984
AGE 32 yrs
SEX Female
PRN MG875244
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
Patient identifying details and demographics
FIRST NAME Michelle
MIDDLE NAME
–
LAST NAME Gibbler
SSN –
SEX Female
DATE OF BIRTH 05/16/1984
DATE OF DEATH –
PRN MG875244
ETHNICITY Not Hispanic or
Latino
PREF.
LANGUAGE
English
RACE Black or African
American
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 123 S. 45th St.
ADDRESS LINE 2 –
CITY Anytown
STATE NY
ZIP CODE 12345
CONTACT BY Home Phone
EMAIL Michelle.Gibbler
@testpatient.com
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN Josephine Gibbler
RELATION TO PATIENT Mother
PHONE 5555555555
ADDRESS 2345 78th St
Haverhill, OH 45636
PATIENT’S MOTHER’S
MAIDEN NAME
Johnson
Free cloud based EHR
Patient chart – Patient: Michelle Gibbler DOB: 05/16/1984 PR… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 1 4/7/17, 5:11 PM
Northstar Surgical Group
5678 Sunshine Way #500
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Michelle Gibbler
DOB: 05/16/1984
Preoperative Diagnoses: Endometriosis, dysmenorrhea, hx of intrauterine device perforation and
exploratory surgery
Procedure Performed: Left salpingo-oophorectomy
Intraoperative Findings:
Perineum and vulva are without lesions. On bimanual examination, palpation revealed the uterus to be
enlarged and retroverted. Intra-abdominal findings revealed normal liver margin, kidneys, and stomach.
The left fallopian tube appeared to be normal size and showed evidence of a functional cyst. Multiple
adhesions were present upon examination of the left ovary.
Procedure Details:
After informed consent was obtained, the patient was delivered to the OR and placed under general
anesthesia. She was then prepped and draped in the usual, sterile manner. In a supine position, a Foley
catheter was placed.
A sagittal midline incision was made and fascia was divided. The peritoneum was entered and observed.
Washings were obtained. Exploration of the abdomen revealed findings as noted above. A retractor was
placed and bowel was packed. Clamps were placed on the left broad ligament to improve traction. The
retroperitoneal spaces were opened by incising lateral and parallel to the left infundibulopelvic
ligament. The left ovarian ligament was identified and two hemostats were placed across the ovarian
ligament. Using the Mayo scissors, the ovarian ligament was transected and dissected down the broad
ligament. The left ovary was dissected in a similar fashion. The peritoneum overlying the vesicouterine
fold was incised to mobilize the bladder. After the pelvis had been irrigated, excellent hemostasis was
noted.
Retractors were repositioned to allow exposure for the left salpingectomy. Borders of the fallopian tube
were identified. The posterior border of dissection was the retroperitoneal cavity, which was carefully
identified and preserved. Ligaclips were applied to the left suspensory ligament. The left fallopian tube
was dissected proximally. The suspensory ligament was dissected at its tubal attachment site, allowing
the fallopian tube to be extracted. After the left salpingectomy was performed, excellent hemostasis
was noted.
All packs and retractors were removed and the abdominal wall was closed using a permanent
monofilament suture. Irrigation of subcutaneous tissues was performed and a Jackson-Pratt drain was
placed. At the completion of the procedure, all instrument, sponge, and needle counts were correct.
The patient was taken to the recovery are and then awakened from her anesthetic in stable condition.
Physician’s Signature John R. Benjamin, MD
Northstar Physical Therapy
6789 Sunshine Way #600
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Michelle Gibbler
DOB: 05/16/1984
Referring Physician: Nazir Asaad, MD
Diagnoses/Reason for PT Referral:
Hx of Endometriosis and dysmenorrhea; 2 weeks post-surgical LSO
Onset date: 2/5/15
Relevant S&S: Pelvic pain, lumbalgia, metrorrhagia
Plan of Care
Interventions:
X Evaluation Gait training X Electrotherapy
X Patient Education Balance training/activities Prosthetic training
X Therapeutic Exercise Pulmonary physical therapy TENS
Transfer training X Ultrasound Teach bed mobility skills
Use of adaptive device Teach fall safety X Heat/cold therapy
X Therapeutic massage X Trigger point therapy
Treatment Frequency:
Office visit 2x/wk for 6 weeks
Modalities:
Patient education- Educate patient on muscular control for Kegal exercises. For 20 reps.
Therapeutic exercise- Guided nutation/counternutation of the SI joints 10 reps x3
Therapeutic massage- Myofascial release 30 min
Ultrasound- SI joints 10 min @ 1MHz; anterior pelvis 10 min @ 1MHz
Electrotherapy- Interferential electrical stimulation 20min @ 80-150Hz – L-S spin
Trigger point therapy- PRN (hip rotators, iliopsoas, QL, abdominals)
Heat/cold therapy- Heat before tx, cold post-tx. Alternating heat/cold at home
Physical Therapy Goals:
Current Level Goals
Moderate urinary incontinence daily Eliminate incontinence
Moderate-Severe pelvic pain rated 6/10 on
average
Reduce pain to 3/10 over 6 weeks; re-evaluate
for further therapy to eliminate pain
Tolerance to ADLs: Mod-severe pain is limiting
work performance
Tolerance to ADLs: No pain, leading to no
limitation to work performance
Pelvic/abdominal cramping at least 1x/week Eliminate pelvic/abdominal cramping
Discharge Plan:
Re-evaluate after 6 weeks of treatment (12 visits)
Rehabilitation Potential:
Poor Fair Good X Excellent
Physical Therapist’s Signature Olivia Pham, D.P.T.
PATIENT
Todd K Anderson
DOB 03/05/1970
AGE 47 yrs
SEX Male
PRN JR572205
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
Patient identifying details and demographics
FIRST NAME Todd
MIDDLE NAME K
LAST NAME Anderson
SSN 123-12-2311
SEX Male
DATE OF BIRTH 03/05/1970
DATE OF DEATH
–
PRN JR572205
ETHNICITY Hispanic or
Latino
PREF.
LANGUAGE
English
RACE White
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 45 Deer Run
Road
ADDRESS LINE 2 –
CITY Livingston
STATE NJ
ZIP CODE 07039
CONTACT BY Email
EMAIL todda@testpatie
nt.com
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN Jessie Anderson
RELATION TO PATIENT Spouse
PHONE 5555555555
ADDRESS 45 Deer Run Ln
Livingston, NJ 07039
PATIENT’S MOTHER’S
MAIDEN NAME
–
Free cloud based EHR
Patient chart – Patient: Todd K Anderson DOB: 03/05/1970 PRN… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 1 4/7/17, 5:12 PM
Northstar Surgical Group
5678 Sunshine Way #500
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Todd K Anderson
DOB: 03/05/1970
Indications: Patient with large renal calculus.
Procedure: Percutaneous Nephrolithotomy
The patient was placed in the supine position, given general anesthesia, then prepped and draped in the
usual standard sterile manner. A flexible cystoscope was then placed into the urethral meatus and the
length of the urethra inspected. No lesions noted.
The bladder neck and trigone showed no abnormalities. The ureteral orifices were noted to be normal
bilaterally. A routine inspection of the bladder was completed with no sign of obvious lesions. A cone tip
catheter was placed into the ureteral orifice. Under fluoroscopic visualization, a retrograde
ureteropyelogram with diluted contrast was performed. No obvious lesions were noted. A 0.3 guide
wire was passed through the ureter and into the renal pelvis. An urteral occlusion balloon catheter was
passed over the wire and the balloon was inflated with contrast. The bladder was drained, wires
removed, scope removed under direct vision.
The patient was then repositioned in the prone position, prepped and draped again in the usual, sterile
manner. A 0.04 guide wire was passed through the previously placed nephrostomy tube. The
nephrostomy tube was then removed over the wire. The tract was dilated to accommodate an
introducer sheath of 10 French size. A safety wire was passed into the renal pelvis and into the ureter
past the ureteral occlusion balloon and secured for emergency use. Sequential dilation was performed
to insert a fascial dilator balloon. This balloon was inflated with contrast to 20 atmospheres of pressure
under fluoroscopy over a period of 5-10 minutes. Then, a 30 French sheath was passed over the balloon
into the inter-renal calyx. The balloon was deflated and removed. The nephroscope was introduced. An
inspection of the renal pelvis identified the stone. No lesions were identified. The stone was fragmented
with an ultrasound lithotripter. Larger fragments of calculi were removed intact with forceps until the
patient was free of all calculi. The renal collecting system was inspected with the nephroscope and
flexible nephroscopy to verify no additional stone material remained. Fluoroscopy was used to verify the
absence of stone material. The guide and safety wires were removed. The nephrostomy tube was
secured to the skin with a nylon suture. The cook catheter was capped. The wound was cleaned and
bandaged. Patient was then awakened from anesthesia without complications and transferred to
recovery. The patient is in stable condition and without complications.
Physician’s Signature Selena Hensen, MD
Northstar Nutritional Services
4567 Sunshine Way #400
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Todd K Anderson
DOB: 03/05/1970
Referring Physician: Nazir Asaad, MD
Medical Nutritional Care Plan
Current Diagnoses: Nephrolithiasis
Relevant S&S: Colic, Oliguria, Pyuria, Dysuria, Lumbalgia
Relevant Lab Findings: Hematuria, dark amber urine
Current BMI: 33.9
Estimated energy needs: 3283 calories per day
Estimated protein needs: 56-72 grams per day
Estimated carbohydrate needs: 179 grams per day
Estimated fat needs: 40-45 grams per day
Nutrition Prescription:
Increase water consumption daily. Decrease sodium intake. (Patient provided with information on DASH
diet.) Include more alkaline foods, such as root vegetables, leafy greens, garlic, lemon, and cayenne
peppers. Switch to olive oil for cooking vegetables and lean meats.
Calculation of therapeutic diet for certain disease states:
Nephrolithiasis: Restrict high-oxalate foods; restrict animal protein
Family hx of hypertension: Reduce sodium intake to below 1500 mg/day
Family hx of gouty arthritis: Reduce meat and fish intake. Replace protein sources with dairy products
and legumes.
Nutrition-related medical condition goals:
Intervention #1: Increase fluid intake
Goal(s): High fluid intake will be this patient’s first priority intervention. Goal is to consume two liters of
water daily. This fluid intake should be spread evenly throughout the day. Bladder should be emptied as
needed. Voluntary urine retention is highly discouraged.
Intervention #2: Alkalinize diet
Goal(s): Due to family history of gouty arthritis (father and paternal GF), it is suggested that the patient
alkalinize his diet to prevent uric acid lithogenesis. The measurable goal is to maintain a urine pH above
6.5 through hydration and potassium citrate solution (30 mEq/day).
Counselor’s Signature Francie McClanahan, R.D.
Module 05 Course Project: Treatment Notes
Each question is associated with the treatment notes provided. Refer to these when answering each question. Please type your answer in the “Click here to enter text” space.
Patient A – Todd Anderson
What surgical procedure was performed on Todd?
Click here to enter text.
What are the two word roots found in “nephrolithotomy” and what are their meanings?
Click here to enter text.
What is the first surgical instrument mentioned in Todd’s surgical report. (Hint: it is used for visual examination.)
Click here to enter text.
In Todd’s surgical report, the ureteral orifices were normal. What does the term “ureteral orifice” mean?
Click here to enter text.
In Todd’s surgical report, what type of tube was used to form an opening into the kidney?
Click here to enter text.
In Todd’s surgical report, what type of instrument was used to break the stones? Briefly describe how it works.
Click here to enter text.
Define fluoroscopy.
Click here to enter text.
Todd’s nutritional care plan lists 5 signs and symptoms. Define each of those terms.
Click here to enter text.
In Todd’s nutritional care plan, which of his conditions is the reason to restrict high-oxalate foods?
Click here to enter text.
Todd’s nutritional counselor makes dietary recommendations to prevent “lithogenesis.” Define this term.
Click here to enter text.
Patient B – Michelle Gibbler
In Michelle’s surgical report, which two reproductive organs are being removed?
Click here to enter text.
In Michelle’s intraoperative findings, which two pelvic structures are found to be normal (without lesions)?
Click here to enter text.
The first incision made in Michelle’s surgical report was a “sagittal, midline” incision. Describe, in your own words, what this incision looks like anatomically.
Click here to enter text.
Michelle’s surgical report uses the word “vesicouterine.” List and define the word parts that make up this term.
Click here to enter text.
The term “peritoneum” is mentioned several times in Michelle’s surgical report. What does it mean?
Click here to enter text.
In Michelle’s surgical report, which anatomical structure was the “posterior border” of the dissection?
Click here to enter text.
Which word is used twice in Michelle’s surgical report to explain that bleeding was controlled (bleeding was stopped)?
Click here to enter text.
Michelle’s physical therapy care plan lists pelvic pain and 2 other signs and symptoms of her condition. List and define these two terms.
Click here to enter text.
In Michelle’s PT care plan, her reason for care is listed as “post-surgical LSO.” What does LSO stand for in this context?
Click here to enter text.
Which of the modalities (therapeutic treatment) listed in Michelle’s PT care plan uses high frequency sound waves to treat musculoskeletal conditions?
Click here to enter text.
References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
Click here to enter text.
You will also likely need to use other course materials or resources to answer all of this assignment’s questions. If you used other references, cite them here:
Click here to enter text.
*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa
Select “References” on the left-hand panel and choose the type of reference you used.
Page 1 of 3
Page 2 of 3