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Question: Review each of the following unrelated statements abstracted from problem-oriented medical record...

Show transcribed image text Review each of the following unrelated statements abstracted from problem-oriented medical record (POMR) documentation. Determine whether each statement is a subjective (S), objective (O), assessment (A), or plan (P) entry from the patient records. ______ Rule out myocardial infarction. ______ Patient complains of pain in the left ear and upon neck movement. ______ BP 130/80, Pulse 85, Respirations 20. Temperature 98.6. Lungs clear. Heart regular. Abdomen nontender. ______ Compare baseline mammogram 2006 to current mammogram. ______ Uncontrolled hypertension. ______ Chest pain. ______ Pedal edema was 2+. ______ Possible aortic aneurysm. ______ Rule out cancerous tumor following biopsy of thyroid lesion. ______ Patient complained of headache, fatigue, and photosensitivity. ______ Patient states, "I am thirsty all the time." Discharge home with home health nursing and durable medical equipment. Follow-up in 1 week with Dr. Brandley. Home medications of Plavix 75mg, Zetia 10mg, Norvasc 25mg. and Tricor 145mg. ______ BUN 21.0mg/dL, ALB 6.0gm/dL, bilirubin total 6.3mg/dL. ______ Percussion was normal. ______ MRI brain with and without contrast: negative findings. ______ Complaining of pain in the low back. ______ Chest x-ray: negative. EKG: A-fibrillation. Total LDH: 145. ______ Laceration measured 2 cm above right brow. ______ Determine treatment following results of radiology studies. ______ Surgical Pathology Frozen Section: Lung LLL. Wedge Biopsy reflects nonsmall cell carcinoma involving pleural nodule.

Review each of the following unrelated statements abstracted from problem-oriented medical record (POMR) documentation. Determine whether each statement is a subjective (S), objective (O), assessment (A), or plan (P) entry from the patient records. ______ Rule out myocardial infarction. ______ Patient complains of pain in the left ear and upon neck movement. ______ BP 130/80, Pulse 85, Respirations 20. Temperature 98.6. Lungs clear. Heart regular. Abdomen nontender. ______ Compare baseline mammogram 2006 to current mammogram. ______ Uncontrolled hypertension. ______ Chest pain. ______ Pedal edema was 2+. ______ Possible aortic aneurysm. ______ Rule out cancerous tumor following biopsy of thyroid lesion. ______ Patient complained of headache, fatigue, and photosensitivity. ______ Patient states, "I am thirsty all the time." Discharge home with home health nursing and durable medical equipment. Follow-up in 1 week with Dr. Brandley. Home medications of Plavix 75mg, Zetia 10mg, Norvasc 25mg. and Tricor 145mg. ______ BUN 21.0mg/dL, ALB 6.0gm/dL, bilirubin total 6.3mg/dL. ______ Percussion was normal. ______ MRI brain with and without contrast: negative findings. ______ Complaining of pain in the low back. ______ Chest x-ray: negative. EKG: A-fibrillation. Total LDH: 145. ______ Laceration measured 2 cm above right brow. ______ Determine treatment following results of radiology studies. ______ Surgical Pathology Frozen Section: Lung LLL. Wedge Biopsy reflects nonsmall cell carcinoma involving pleural nodule.