Final – Analyzing a Progress Note.DOCX

Final – Analyzing a Progress Note

Using the following progress note, identify the body system that the bolded terms represent.

This patient has admitted herself into the ER to be assessed for a burn.

Progress Note

Patient is a 48 y.o. female who is accompanied by her spouse with complaint of a “burn to the arm”. She was cooking at home and experienced a small grease fire. She was able to contain the fire; however, grease splattered on her right hand and forearm. She noted running her arm under water and wrapping her arm and hand in a clean kitchen towel. Complaints of extreme pain rates level 10/10 to the entire burn area.

History of Present Illness

Patient has a history of polycystic kidney disease resulting in frequent UTI’s. She is currently on Macrobid for a recent infection. History of hypertension. Blood pressure is 162/90. It is elevated at this time due to pain levels. History of anemia for which she takes daily iron tablets. Right forearm with multiple blisters and apparent epidermal loss. Right hand reddened with multiple blisters, epidermal loss, and multiple sites. Patient has a history of IBS. History of hypothyroidism and hypoglycemia. Patient is taking Thyroxin and checks her blood sugars regularly at home. History of peripheral neuropathy and vertigo. She stated she has intermittent feeling or sensation to her fingertips. She notes signs of vertigo when she changes positions quickly sitting to standing. Patient has a history of emphysema. Patient is on home oxygen at night. Pulse ox is 96% on room air. History of osteoporosis. Patient is in early menopause. Her next bone density is scheduled for 6 months.

Impression/Plan

1. 2nd degree burn to the forearm (943.2), burn to the right hand multiple sites (944.8), E895 (Accident caused by controlled fire in private residence). Silvadine ointment wrap applied to the right hand and forearm.

2. Uncontrolled pain: Tylenol#3 administered.

3. Plan to admit to medical surgical floor for management of wounds and pain control: 24-hour observation. Assess vital signs every 4 hours, continue home medications, oxygen 1 liter at night, Accu-Check fasting and at night, Tylenol #3 every 4-6 hours 1-2 tablets as needed for pain, lab to draw a CBC and chemistry level. Consult Dr. Jackson in Dermatology for further orders.

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