Discharge Summary: The Cardiorespiratory System

Discharge Summary: The Cardiorespiratory System

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  • Translate into medical terms or abbreviations common terms contained in a patient’s discharge summary. Identify 5 drugs appearing in the discharge summary and specify the usage reason for each drug on the provided template. Record yourself reading the patient’s discharge summary (1-2 single spaced pages).

Assessment 5 continues the exploration of medical terminology related to various body systems and the general structure and functions of the human body. In this assessment, you will focus your attention on the cardiorespiratory system, a specialized area of medicine. The cardiorespiratory system refers to the ability of the circulatory and respiratory systems to supply oxygen to skeletal muscles during sustained physical activity. You will have an opportunity to demonstrate your knowledge of this system’s purpose, various parts, and importance to overall body functioning. In addition, you will demonstrate your knowledge of cardiorespiratory diseases, diagnostic studies, and treatments, including pharmacology. 

In the assessment you will review a discharge summary for a patient with cardiorespiratory disease and demonstrate your command of medical terminology, including your pronunciation of the terms through an audio recording.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: 

  • Competency 1: Use medical terminology and abbreviations related to pharmacology.
    • Identify drugs correctly.
    • Specify the correct reason for the drug’s use.
  • Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.
    • Identify common terms related to general structures and functions of the human body correctly.
    • Translate common terms related to general structures and functions of the human body into medical terms or abbreviations correctly.
  • Competency 3: Use medical terminology and abbreviations related to body systems.
    • Identify common terms related to body systems correctly.
    • Translate common terms related to body systems into medical terms or abbreviations correctly.
  • Competency 4: Use medical terminology and abbreviations related to specialized areas of medicine.
    • Identify common terms related to specialized areas of medicine correctly.
    • Translate common terms related to specialized areas of medicine into medical terms or abbreviations correctly.
  • Competency 6: Spell and pronounce basic medical terms.
    • Spell common and medical terms or abbreviations correctly.
    • Pronounce medical terms correctly.
  • Competency 7: Communicate in a professional manner.
    • Use volume, tone, and clarity reflective of professional communication in a health care setting.
    • Provide citations and references in APA style.

Preparation

To prepare for your audio recording of the discharge summary:

  • Set up and test your microphone or headset, using the installation instructions provided by the manufacturer.
  • Practice using the equipment to ensure the audio quality is sufficient.
  • Consult the Using Kaltura [PDF] for guidance in how to record your discharge summary and upload it in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact Disability Services to request accommodations.

Instructions

Review the patient’s discharge summary below. Next, download the Discharge Summary Template [DOCX] and complete all of the following:

  • Identify 10 common terms contained in the discharge summary and correctly translate them into medical terms or abbreviations. Remember, you must spell the common and medical terms or abbreviations correctly.
  • Identify 5 drugs that appear in the discharge summary and specify the reason each drug is used.
  • Cite in correct APA style the references you used to perform your translation. 

The final step in this assessment is to record yourself reading the discharge summary with the correct medical terms. In your recording, you need to correctly pronounce all the medical terms. In addition, be sure to use appropriate tone, volume, and clarity for professional communication in the health care field. Submit your Discharge Summary Template and your audio recording of the discharge summary to the appropriate area in the courseroom.

Discharge Summary: Cardiorespiratory

Discharge Diagnosis

  • Non-ST-elevation myocardial infarction.
  • Moderate coronary artery disease.
  • Stroke.
  • High blood pressure.
  • An abnormally high concentration of lipids in the blood.
  • Chronic obstructive pulmonary disease.
  • Chronic systolic congestive heart failure.

Procedures

Left heart catheterization, medical imaging test to determine cardiac function in the left ventricle, medical imaging used to visualize coronary arteries with stent placement, computed tomography scan, magnetic resonance imaging scan, posterior artery in the brain repair with stent placement.

Brief History

This 72-year-old male presented to the emergency room with chest pain, shortness of breath, and left arm numbness. Patient has a history of high blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure. In the emergency room, troponin levels and EKG results came back positive for Non-ST-elevation myocardial infarction. Patient was taken directly to the cardiac catheterization lab.

Past Medical History

High blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure, asthma as a child, previous right total knee replacement.

Medications

Norvasc, Lipitor, Lasix, Cozaar, oxygen dependent.

Family History

Patient is adopted and does not know family history; all children are healthy.

Social History

Former smoker, no alcohol or illegal drugs.

Allergies

Penicillin, Sulfa.

Physical Exam

GENERAL: Alert and oriented X3.

HEENT: Normocephalic and atraumatic, blindness over half the field of vision.

LUNGS: Few rales in lower lobes.

HEART: RRR without murmur.

ABDOMEN: Soft, non-tender, without swelling or masses.

EXTREMITIES: 2+ edema in lower extremities, no cyanosis.

Hospital Course

This is a 72-year-old male who was taken directly to the cardiac catheterization lab from the emergency department due to an evolving Non-ST-elevation myocardial infarction. A 98% close to the center right coronary artery lesion was treated with a Cypher 3.5 x 13 mm stent. The left descending artery showed 35% stenosis, and the left circumflex artery showed 25% stenosis. The image of the left ventricle demonstrated an ejection fraction of 40%. Following the procedure, the patient was admitted to the telemetry unit for observation. He remained in stable condition without chest pain but developed an irregular, rapid heartbeat. The next day, the patient complained of a severe headache in the back of his head with double vision and only being able to see from half of his eye. The patient was taken for a computed tomography scan and magnetic resonance imaging scan which showed a blood clot blocking the posterior artery in the brain. The patient was take back to the catheterization room where a catheterization of the head artery was performed to remove the blood clot and to place a stent to keep the vessel open. Patient is being discharged home on routine meds to follow up with primary care physician within 7 days.

Additional Requirements

  • Format: Be sure to complete all columns on the Discharge Summary Template.  
  • Submission: Be sure to submit to all of the following to the appropriate area in the courseroom:
    • The Discharge Summary Template.
    • Your audio recording of the discharge summary.
  • Scoring Guide:  Be sure to read this assessment’s scoring guide, so you understand how your faculty member will evaluate your Discharge Summary Template and your audio recording.
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