Prompt
Your patient analysis should answer the following prompt: Using the provided Final Project Patient File, critically analyze the patient’s medical and family history and dissect the discharge chart from the patient’s recent visit. There are several inaccuracies and inconsistencies in this patient file; the pages of the file that contain issues are marked in the upper right-hand corner with red bookmarks. You must identify a total of three true issues with the patient file, explain what makes each identified issue a true issue, and discuss how you would approach addressing each issue in a real professional setting.
Specifically, the following critical elements must be addressed:
Patient History Analysis
Summarize the patient history, explaining key patient demographics and family history that could be risk factors for common diseases.
Identify the past diagnosis (or diagnoses, if more than one exists in the file) and explain how the diagnosis was made. Specifically, what tests were done?
Discuss the symptoms the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?
What alternate diagnosis (or diagnoses) could these symptoms have indicated? Explain using evidence-based resources to support your conclusions.
Using supportive details from peer-reviewed resources, explain the pathophysiology of the diagnosis. In other words, how does the diagnosed disease develop and progress in the body?
Identify the past prescribed medications the patient is taking and explain the purposes of their larger pharmacological groupings.
Explain what symptoms the specific medications are meant to treat, using resources to support your claims about the impact of the medication on the symptoms.
Illustrate how these medications impact the body and its functions. Use examples to support your explanations.
Recent Visit Analysis
Explain why the patient has returned to the doctor’s office. What symptoms and signs is the patient experiencing?
Analyze the new symptoms and signs to determine whether the past diagnosis is still a reasonable conclusion or could have been a misdiagnosis. Use specific information from both the recent visit and the patient history to inform your analysis.
Based on the new signs, symptoms, and potential diagnosis (if the doctor has made a new diagnosis), discuss what new or potential treatments would be appropriate. Why?
Identification of Record Inaccuracies
The patient file contains several inaccuracies and inconsistencies. Using your knowledge of medical terminology, anatomy, and physiology, articulate three issues you’ve identified.
Explain in detail what makes the identified issues a problem in terms of patient health and record keeping. Be sure to use appropriate medical terminology, references to anatomy, and concepts of normal physiology, where appropriate.
Discuss the impact of the issues on the patient, the coding system, and the billing system if they had not been caught, using the appropriate terminology.
Illustrate how you would work to address each issue, with specific detail regarding who you would pull into the discussion and who would be responsible for the particular details of each issue in a real medical setting.
