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Patient Documentation Analysis
Due Date
Sunday 11:59 p.m. MT (Try to make your first post by Wednesday.)
Instructions
(Required) Select the tabs to review the patient medical report. Detailed discussion questions
follow below.
Identify one or two medical terms in this report. Deconstruct the components of specific medical
terms to identify their meanings. In addition, please pay attention to the spelling and pronunciation
of the words.
Case Study #1
Discharge Summary
The patient, John Madison, is an 8-month old white male presenting a viral type syndrome.
Admission Diagnosis
Bronchiolitis with hyperpyrexia; history of premature delivery with one hospitalization for lung
immaturity at time of birth.
Discharge Diagnosis
Bronchiolitis with fever and poor fluid intake.
Summary
John Madison is an 8-month-old white male seen by Dr. White at the Lofty Pines Health Center for
a viral-type syndrome. The mother states that the baby had a temperature over the weekend,
going up to 103 and 104 the night prior to admission. The baby has progressively gotten more
worked up, more short of breath, and has had respiratory disease. The patient was hospitalized for
his respiratory distress and lower respiratory disease.
Positive physical exam on admission included both lung fields filled with rhonchi and occasional
rales. There were no signs of consolidation. The patient was put in a croup tent during his hospital
stay and was placed on Ampicillin four times a day for his two-day course. He tolerated the croup
tent well and the antibiotics. His lungs progressively cleared, and the patient was discharged on
02-11-2018. He was discharged on the instructions to force fluids, saline nose drops, and bulb
suction as needed, Amoxicillin 125 milligrams three times a day, and to return to the clinic in one
week to see Dr. Swisher.
Lab Data
White count was 10.7, hemoglobin was 12.2, hematocrit was 37.7, 13 segmented cells, 77
lymphocytes, 10 monocytes. Chest x-ray was within normal limits.
Discussion Questions
Question 1
Review the Inpatient Discharge Summary of John Madison (Case Study 1) and provide the
following in your post.
Conduct research on bronchiolitis, using available library resources and trustworthy medical
websites such as the Mayo Clinic. Post a one-paragraph summary on bronchiolitis, and cite your
source. Use the information youve gathered from your research to address the following questions
in b. and c. below.
What is bronchiolitis, and what are its symptoms and some risk factors for developing it? In the
discharge summary, the baby was seen for a "viral-type" syndrome. What is the likely name for
this virus, which causes most cases of bronchiolitis?
Differentiate between the terms "rhonchi" and "rales" that are referred to in the discharge
summary. What is a croup tent and why was Ampicillin given to the baby?

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Patient Documentation Analysis Due Date Sunday 1159 pm MT.pdf

  • 1. Patient Documentation Analysis Due Date Sunday 11:59 p.m. MT (Try to make your first post by Wednesday.) Instructions (Required) Select the tabs to review the patient medical report. Detailed discussion questions follow below. Identify one or two medical terms in this report. Deconstruct the components of specific medical terms to identify their meanings. In addition, please pay attention to the spelling and pronunciation of the words. Case Study #1 Discharge Summary The patient, John Madison, is an 8-month old white male presenting a viral type syndrome. Admission Diagnosis Bronchiolitis with hyperpyrexia; history of premature delivery with one hospitalization for lung immaturity at time of birth. Discharge Diagnosis Bronchiolitis with fever and poor fluid intake. Summary John Madison is an 8-month-old white male seen by Dr. White at the Lofty Pines Health Center for a viral-type syndrome. The mother states that the baby had a temperature over the weekend, going up to 103 and 104 the night prior to admission. The baby has progressively gotten more worked up, more short of breath, and has had respiratory disease. The patient was hospitalized for his respiratory distress and lower respiratory disease. Positive physical exam on admission included both lung fields filled with rhonchi and occasional rales. There were no signs of consolidation. The patient was put in a croup tent during his hospital stay and was placed on Ampicillin four times a day for his two-day course. He tolerated the croup tent well and the antibiotics. His lungs progressively cleared, and the patient was discharged on 02-11-2018. He was discharged on the instructions to force fluids, saline nose drops, and bulb suction as needed, Amoxicillin 125 milligrams three times a day, and to return to the clinic in one week to see Dr. Swisher. Lab Data White count was 10.7, hemoglobin was 12.2, hematocrit was 37.7, 13 segmented cells, 77 lymphocytes, 10 monocytes. Chest x-ray was within normal limits. Discussion Questions Question 1 Review the Inpatient Discharge Summary of John Madison (Case Study 1) and provide the following in your post. Conduct research on bronchiolitis, using available library resources and trustworthy medical
  • 2. websites such as the Mayo Clinic. Post a one-paragraph summary on bronchiolitis, and cite your source. Use the information youve gathered from your research to address the following questions in b. and c. below. What is bronchiolitis, and what are its symptoms and some risk factors for developing it? In the discharge summary, the baby was seen for a "viral-type" syndrome. What is the likely name for this virus, which causes most cases of bronchiolitis? Differentiate between the terms "rhonchi" and "rales" that are referred to in the discharge summary. What is a croup tent and why was Ampicillin given to the baby?