270 Medical Terminology: Mastering the Basics Analyzing the Intern Experience In the Intern Experience described at the beginning of this chapter, we met Debra, an intern with University Eye and Ear Specialists. Debra met Mrs. Rodri- guez and her four-year-old son, Juan, when the young boy was brought to the doctor’s offi ce because of severe otalgia (ear pain). A physician examined Juan and obtained his personal and family health his- tory from Mrs. Rodriguez. The doctor then made a medical diagnosis and provided Juan’s mother with a treatment plan. Later, the physician made a dictated record- ing of the patient’s health information, which was subsequently transcribed into a chart note. We will now learn more about Juan’s condition from a clinical perspective, interpreting the medical terms in his chart note as we analyze the scenario pre- sented in the Intern Experience. Audio Activity: Juan Rodriguez’s Chart Note Directions: At the companion website, listen and read along as the physician dictates Juan Rodriguez’s chart note, shown below. Then do the exercise that appears after the chart note. CHART NOTE Patient Name: Rodriguez, Juan ID Number: JR4239 Examination Date: February 6, 20xx SUBJECTIVE This 4-year-old male patient was brought in by his mother, who states he had a cold last week. He woke up this morning screaming, felt hot, and was tugging on his left ear. This is the third episode this year. Mother concerned with potential hearing loss. OBJECTIVE Temperature is 102.5° F and pulse is 100. Left tympanic membrane is dull, red, and bulging. Eyes are clear. Nose and throat clear. Neck is supple without adenopathy (disease of gland tissue). Lungs are clear. ASSESSMENT Left acute otitis media. PLAN Augmentin® (penicillin) 250 mg t.i.d. (three times a day) x 10 days. Recheck at end of treatment. Due to her concern with a hearing loss, I discussed a tympanometry evaluation and/or referral to an otorhinolaryngologist (ENT), an ear, nose, and throat specialist.
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