In this course project assignment, you are presented with treatment
notes for two different patients. Treatment Notes often include
medication orders, medication administration, and documentation of
procedures, such as physical therapy, respiratory therapy, nutrition
counseling, and radiation therapy. These notes include details regarding
the type, length, and necessity of treatment. Treatment notes are
important to track the execution of the patient’s treatment plan and
monitor progression of his or her health outcomes.
You will be exploring the medical terminology used in these test
results and will be asked to interpret the meanings of various words and
abbreviations.
To complete this assignment, do the following:
Download the treatment notes for the two patients: Michelle Gibbler Treatment Notes Todd Anderson Treatment Notes Download, complete, and submit the document below. This document contains questions you will answer regarding the treatment notes for each patient. Module 05 Course Project Assignment Template
PATIENT
Michelle Gibbler
DOB 05/16/1984
AGE 32 yrs
SEX Female
PRN MG875244
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
Patient identifying details and demographics
FIRST NAME Michelle
MIDDLE NAME –
LAST NAME Gibbler
SSN –
SEX Female
DATE OF BIRTH 05/16/1984
DATE OF DEATH –
PRN MG875244
ETHNICITY Not Hispanic or
Latino
PREF.
LANGUAGE
English
RACE Black or African
American
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 123 S. 45th St.
ADDRESS LINE 2 –
CITY Anytown
STATE NY
ZIP CODE 12345
CONTACT BY Home Phone
EMAIL Michelle.Gibbler
@testpatient.com
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN Josephine Gibbler
RELATION TO PATIENT Mother
PHONE 5555555555
ADDRESS 2345 78th St
Haverhill, OH 45636
PATIENT’S MOTHER’S
MAIDEN NAME
Johnson
Free cloud based EHR
Patient chart – Patient: Michelle Gibbler DOB: 05/16/1984 PR… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 1 4/7/17, 5:11 PM
Northstar Surgical Group
5678 Sunshine Way #500
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Michelle Gibbler
DOB: 05/16/1984
Preoperative Diagnoses: Endometriosis, dysmenorrhea, hx of intrauterine device perforation and
exploratory surgery
Procedure Performed: Left salpingo-oophorectomy
Intraoperative Findings:
Perineum and vulva are without lesions. On bimanual examination, palpation revealed the uterus to be
enlarged and retroverted. Intra-abdominal findings revealed normal liver margin, kidneys, and stomach.
The left fallopian tube appeared to be normal size and showed evidence of a functional cyst. Multiple
adhesions were present upon examination of the left ovary.
Procedure Details:
After informed consent was obtained, the patient was delivered to the OR and placed under general
anesthesia. She was then prepped and draped in the usual, sterile manner. In a supine position, a Foley
catheter was placed.
A sagittal midline incision was made and fascia was divided. The peritoneum was entered and observed.
Washings were obtained. Exploration of the abdomen revealed findings as noted above. A retractor was
placed and bowel was packed. Clamps were placed on the left broad ligament to improve traction. The
retroperitoneal spaces were opened by incising lateral and parallel to the left infundibulopelvic
ligament. The left ovarian ligament was identified and two hemostats were placed across the ovarian
ligament. Using the Mayo scissors, the ovarian ligament was transected and dissected down the broad
ligament. The left ovary was dissected in a similar fashion. The peritoneum overlying the vesicouterine
fold was incised to mobilize the bladder. After the pelvis had been irrigated, excellent hemostasis was
noted.
Retractors were repositioned to allow exposure for the left salpingectomy. Borders of the fallopian tube
were identified. The posterior border of dissection was the retroperitoneal cavity, which was carefully
identified and preserved. Ligaclips were applied to the left suspensory ligament. The left fallopian tube
was dissected proximally. The suspensory ligament was dissected at its tubal attachment site, allowing
the fallopian tube to be extracted. After the left salpingectomy was performed, excellent hemostasis
was noted.
All packs and retractors were removed and the abdominal wall was closed using a permanent
monofilament suture. Irrigation of subcutaneous tissues was performed and a Jackson-Pratt drain was
placed. At the completion of the procedure, all instrument, sponge, and needle counts were correct.
The patient was taken to the recovery are and then awakened from her anesthetic in stable condition.
Physician’s Signature John R. Benjamin, MD
Northstar Physical Therapy
6789 Sunshine Way #600
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Michelle Gibbler
DOB: 05/16/1984
Referring Physician: Nazir Asaad, MD
Diagnoses/Reason for PT Referral:
Hx of Endometriosis and dysmenorrhea; 2 weeks post-surgical LSO
Onset date: 2/5/15
Relevant S&S: Pelvic pain, lumbalgia, metrorrhagia
Plan of Care
Interventions:
X Evaluation Gait training X Electrotherapy
X Patient Education Balance training/activities Prosthetic training
X Therapeutic Exercise Pulmonary physical therapy TENS
Transfer training X Ultrasound Teach bed mobility skills
Use of adaptive device Teach fall safety X Heat/cold therapy
X Therapeutic massage X Trigger point therapy
Treatment Frequency:
Office visit 2x/wk for 6 weeks
Modalities:
Patient education- Educate patient on muscular control for Kegal exercises. For 20 reps.
Therapeutic exercise- Guided nutation/counternutation of the SI joints 10 reps x3
Therapeutic massage- Myofascial release 30 min
Ultrasound- SI joints 10 min @ 1MHz; anterior pelvis 10 min @ 1MHz
Electrotherapy- Interferential electrical stimulation 20min @ 80-150Hz – L-S spin
Trigger point therapy- PRN (hip rotators, iliopsoas, QL, abdominals)
Heat/cold therapy- Heat before tx, cold post-tx. Alternating heat/cold at home
Physical Therapy Goals:
Current Level Goals
Moderate urinary incontinence daily Eliminate incontinence
Moderate-Severe pelvic pain rated 6/10 on
average
Reduce pain to 3/10 over 6 weeks; re-evaluate
for further therapy to eliminate pain
Tolerance to ADLs: Mod-severe pain is limiting
work performance
Tolerance to ADLs: No pain, leading to no
limitation to work performance
Pelvic/abdominal cramping at least 1x/week Eliminate pelvic/abdominal cramping
Discharge Plan:
Re-evaluate after 6 weeks of treatment (12 visits)
Rehabilitation Potential:
Poor Fair Good X Excellent
Physical Therapist’s Signature Olivia Pham, D.P.T.
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