HCS 216 Week 2 Endocrine System – Analyzing a Progress Note

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HCS 216 Week 2 Endocrine System – Analyzing a Progress Note
 

Complete the University of Phoenix Material: Endocrine System – Analyzing a Progress Note.

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Endocrine System – Analyzing a Progress Note

 

Part 1

 

Using the following progress note, define the bolded terms within the chart provided. 

 

This patient is being treated with their primary after visiting the urgent care this weekend.

 

Progress Note

 

Patient is a 45 y.o. female that presents to rule out unstable diabetes. She initially made a visit to the urgent care one day prior with complaints of excessive thirst, urination, and fatigue. Her fasting blood sugar was 350. She was treated and referred to this practice for a consult.

 

History: Patient has a history of polycystic ovarian syndrome, congenital hypothyroidism, benign thyroid nodule, and early menopause.

 

Assessment: Patient’s Accu-Check is currently 400. Her vital signs are stable. She continues to have flu-like symptoms with complaints of nausea and fatigue along with increased urination and excessive thirst.

 

Plan: Direct admission to South Hospital, 24-hour urine test, repeat Accu-Check, thyroid function, cortisol blood test stat. Refer to Dr. Jones, endocrinologist for consult today.

 

Impression: Hyperglycemia (abnormal glucose)

 

Jill Smith DNP

 

*Do not forget to include the sources for your definitions.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
 

 
 

 

Definition
 

 
 

 

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Part 2

 

Complete the following table using the information found in the Progress Note and the Internet. List the appropriate code(s) for the given medical terms and provide a justification explaining why you selected the given medical code(s).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
Medical code
Justification
Sources
Hyperglycemia, 

unspecified
 
 
 
Hypothyroidism 

(Congenital iodine-deficiency syndrome, unspecified)
 
 
 
 

 

 
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