Chapter 3 The Digestive System 123 Audio Activity: Sally Nguyen’s Chart Note Directions: At the companion website, listen and read along as the physician dictates the following chart note on Sally Nguyen. Then do the exercise that appears after Sally’s chart note. CHART NOTE Patient Name: Nguyen, Sally ID Number: 22316 Examination Date: March 1, 20xx PROCECURE Flexible sigmoidoscopy INDICATIONS Patient is an 81-year-old female for routine screening fl exible sigmoidoscopy. Patient has a maternal history of Crohn’s disease and a paternal history of diabetes. PROCEDURE REPORT The 60 cm sigmoidoscope was introduced to 40 cm and was well tolerated. Erythematous, nonbleeding polyp, less than 1 cm, was found between 35 and 40 cm. Retrofl ex (backward) viewing is negative. Patient tolerated the procedure well. DIAGNOSIS Polyp at 35-40 cm on fl exible sigmoidoscopy screening examination. PLAN She is referred to a gastroenterologist for colonoscopy. We discussed the risks of colonoscopy, its benefi ts, and the procedure. The patient was provided with a brochure describing the procedure and instructed to contact the offi ce with any questions. Assessment Interpret Sally Nguyen’s Chart Note Directions: After listening to the dictated recording and reading the chart note on Sally Nguyen, provide the medical term that matches each defi nition below. Example: inflammation of the stomach Answer: gastritis 1. process of observing the colon ________________________________________________ 2. specialist in the study of the stomach and intestine ________________________________________________ 3. instrument used to visualize the sigmoid colon ________________________________________________ 4. process of observing the sigmoid colon ________________________________________________ SCORECARD: How Did You Do? Number correct (_____), divided by 4 (_____), multiplied by 100 equals _____ (your score)
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