120 Medical Terminology: Mastering the Basics Analyzing the Intern Experience In the Intern Experience described at the beginning of this chapter, Evan Walker encountered Sue, a young female patient who had diffi culty swallowing. Sue was seen by Dr. Stomack, who obtained a history of her health problems and per- formed a physical examination. In addition, Dr. Stomack ordered a diagnostic test to help determine the cause of Sue’s condition. When she received the test results, Dr. Stomack analyzed all the information that she had gathered, made a medical diagnosis, and developed a treatment plan. The physician then made a dictated recording of Sue’s health information, which was later transcribed into a chart note. We will now learn more about Sue’s condition from a clinical perspective, inter- preting the medical terms in her chart note as we analyze the scenario presented in the Intern Experience. Audio Activity: Sue Resch’s Chart Note Directions: At the companion website, listen and read along as the physician dictates Sue Resch’s chart note, shown below. Then do the exercise that appears after Sue’s chart note. CHART NOTE Patient Name: Resch, Sue ID Number: 76554 Examination Date: March 1, 20xx SUBJECTIVE Sue came into our offi ce complaining of a feeling that something is caught in her throat. She thinks it might be a turkey bone from the soup she ate last night. OBJECTIVE Sensation of a foreign body in the proximal esophagus, near the oropharynx. Vital signs are normal. No known allergies. She states that this happened once before but denies any regular symptoms of dysphagia or gastroesophageal refl ux. ASSESSMENT Sensation of foreign body. PLAN Recommend immediate esophagogastroduodenoscopy to exclude an esophageal foreign body.
Previous Page Next Page