Question

Directions! In many Instances, when developing the skill of reviewing a patient record, you may need critical thinking in addition to efficient use of reference books. Answer only those questions you think can be justified by the documentation presented in the patient's record. Because the content of each record is variable, you may or may not have answers to all eight questions. Answer the questions by recording on the blank lines the documentation found identifying the components from the patient's record. Patient Record 10-21- 2017 HPI This new patient is an 80-year-old white male who has had problems with voiding since 9-5-2017 During the night, the patient had only 50 mL output and was catheterized this morning be- cause of his poor urinary output (200 mL). He was thought to have a distended bladder; he complains of pressure in the suprapubic region. He has not had any gross hematuria. He has difficulty voiding, especially lying down. His voiding pattern is improved while standing and sitting 1. Location: In what body system is the sign or symptom occurring? Response: 2. Quality: Is the symptom or pain burning, gnawing, stabbing, pressure-like, squeezing fullness? Response: 3. Severity: In this case, how would you rank the symptom (how was distress relieved) or pain (slight, mild, severe, persistent)? Response:

Answer 1

Answers:

1. Urinary system

2. Pressure - like

3. Distress relived during standing and sitting. And he has mild pain.

4. Since 9 -5 -2017

6. During night time

7. No, the symptoms is associated with poor urinary output

8. Urinary catheterization, changing the position (sitting, standing) make the symptoms better

Lying position makes the symptoms worse

9. Persistent urinary retention can cause renal failure