Question

Please help... I don't understand discharge summaries yet.

General Hospital 1511 Ninth Avenue Sun City, USA 12345 (544) 802-1234 DISCHARGE SUMMARY DISCHARGE DATE: March 6, 20xox ADMISSION DATE: March 5, 20xx ADMITTING AND DISCHARGE DIAGNOSES: Human immunodeficiency virus infection. s pneumonia Wasting SOCIAL HISTORY: Patient's husband is deceases from AIDS 1 year ago with progressive multifocal leukoencephalopathy and Kaposi sarcoma. She denies any history of intravenous drug use transfusion, and identifies three lifetime sexual partners PAST MEDICAL HISTORY: Patient's past medical history is significant for HIV and several episodes of diarrhea, sinusitis, thrush, and vaginal candidiasis. She gave a history of a 10-pound weight loss. The chest x-ray showed bilateral lower lobe atelectosis, and she was diagnosed with presumptive Pneumocystis pneumonia and placed on Bactrim. She was admitted for a bronchoscopy with alveolar lavage to confirm diagnosis PROCEDURE: The antiretroviral treatment was reinitiated, and she was counseled as to the need to strictly adhere to her therapeutic regimen. DISCHARGE INSTRUCTIONS: Complete medication regimen. Patient discharged to the care of Dr. Amid Shaheen

Answer 1

1. How do you think the patient acquired for HIV infection?

c. From her husband

Usually, the HIV is transmitted through the body fluids of blood, semen, breast milk, and vaginal secretions. It also transmitted if exposed to infected person wounds, secretions and sharing of the needles. This patient history shows that there is no history of blood transfusion and IV injections but she had three-lifetime sexual partners. So she got HIV infection through the unprotected sexual contact. Further, her husband has infected with HIV which also proves the same.

2. Circle the disorder stated in the report, associated with / significant for HIV

a. Vaginal candidiasis

c. Thrush

Vaginal candidiasis is a vaginal yeast infection which increases the risk of sexually transmitted infection in women. Thrush means the excessive growth of yeast in the vagina. This occurs when the immune system is weakened as a cause of HIV infection.

3. The chest-x-ray demonstrated bilateral lower lobe of atelectasis

a) Explain what this means?

Atelectasis means the complete or partial collapse of the lobe of the lung. The lower lobe of both lungs is collapsed in this patient. Alveoli are filled with air which helps in the exchange of gases. But in Atelectasis the alveoli is not filled with air results in damage to smaller portions of the lung.

b) is this disorder in one or both lung. How do you know?

The disorder of atelectasis shows both lungs. The word bilateral says this. bi means both lateral means sides which means both sides of the body. The lower lobe of both sides of the lung gets affected.

4. The patient was admitted for a bronchoscopy to confirm the diagnosis

a. Separate the term with the slash mark

BRONCHOSCOPY

bronch - trachea or windpipe

scope - Instrument used to visualize

b. Define bronchoscopy

An endoscope inserted through the mouth and used to visualize the bronchial tree.

5. The patient is admitted for alveolar lavage. This is what part of the lung

c. Air sacs

alveolar lavage is the washing out by which the bronchioles and air sacs cells and fluids are removed to evaluate and to confirm the diagnosis.