Question Answered step-by-step Number and correct all errors in the following 2 reportsand define… Number and correct all errors in the following 2 reports and define Von Willebrand’s disease. There are 9 errors in the first report. (Number 1-9 and write the error and the correction).#1 DISCHARGE SUMMARY FINAL DIAGNOSES:1.      Massive cerebral adema.2.      Subarachnoid hemorrhage.3.      Cardiopulmonary arrest.4.      Respiratory failure.5.      Von Willebrand disease. CHIEF COMPLAINT ON PRESENTATION: Status post cardiopulmonary arrest. PRESENTATION: The patient was a 16-year-old youngster transferred from another facility. He had had a sore throat with fever the day prior to admission. The family had started penicillin, which they had available at home; however, his aural intake was poor. He had no vomiting and no diarrhea. He was reportedly seen at 7:00 a.m. by his father, who had spoken with him at that time, and then he went up to bed. He was subsequently found by his girlfriend unresponsive at 1:00 p.m. EMS was called and he was resuscitated en route to the referring hospital. There, he was intubated and ventilated. His initial blood gas showed a pH of 6.79, pCO2 of 72, and a pO2 of 315. At that time, he was minimally responsive and his only evidence of brainstem function where occasional agonal respirations.  PAST MEDICAL HISTORY: Significant for von Willebrand disease, with no symptoms. She has a history of chronic otitus as an infant. He had had no recent injuries, including no falls.  ALLERGIES: None.  MEDICATIONS: He was on no medications on admission.  SOCIAL HISTORY: He attended school. There was some question of elicit drug ingestions in the past.  PHYSICAL EXAMINATION: His admission exam revealed that he was comatose and unresponsive. His temperature was 98, heart rate was 150, his blood pressure was 110/70 and his respirations were only on the ventilator. His physical examination was unremarkable apart from his neurologic exam, which demonstrated that both pupils were fixed at 7 mm. No doll’s eyes. No corneal, cough, or gag reflexes. He had occasional agonal respirations. DATA: His labs were unremarkable. CT of his head showed massive serebral edema with subarachnoid hemorrhage.  HOSPITAL COARSE: He was seen and evaluated by the neurosurgeon, who felt there was nothing additional to offer. During his course in the hospital, he progressed to brain death. Prior to this, a long discussion was held with his family regarding their wishes. A Codman monitor was placed to document his intracranial hypertension. The opening pressures were in the 70s. These were higher than the mean blood pressure. He progressed to brain death and was declared brain dead later that evening. Family had requested organ donation; however, due to the amount of pressors he was on to maintain his blood pressure, organ donation was declined by the organ retreival service.  FINAL DISPOSITION: The case was reported to the medical examiner. I do not have the results of the autopsy. Correct all the errors in the following discharge summary. There are 12 errors (number 1-12, write the errors and the correction).#2 DISCHARGE SUMMARY ADMITTING DIAGNOSIS: Pelvic inflammatory disease. Rule out appendiceal abscess. DISCHRAGE DIAGNOSIS: Pelvic inflammatory disease, improved. OPERATIONS: None. COMPLICATIONS: None. BREIF HISTORY AND PHYSICAL: This patient is a 29-year-old gravida 2, para 2 woman who has been having pelvic pain for 3 days prior to admission. She had been seen in my office and found to have a tender uterus but with no Trichomonas, no yeast, no fever, and normal white count. Serum pregnancy test was negative, and patient was seen in the emergency room, subsequently admitted for increasing pelvic pain. LABORATORY AND COURSE IN THE HOSPITAL: CBC on admission showed an 8600 white count, 67 sigs, and no bands. Subsequent CBCs continued to show relatively normal white counts of 6300 and 65000, again with no distinct left shift. A pelvic sonogram revealed a introverted uterus with normal ovaries and an edematous left fallopian tube, which would be consistent with pelvic inflamatory disease. An abdominal sonogram is generally normal, but the head of the pancreas was unable to be evaluated due to bowel gass. Since admission, patient has been treated with Flagyl 500 mg every 8 hours intravenously and 1000 mg of Ancef every 8 hours. She has been treated with Vicidin and/or Darvocet-N 100 for pain. Stadol injections have been given at times, Compazine for nausea, Colace to soften stools, and Milk of Magnesia to move bowels. She has also been given Fleet’s enemas at a time when she had difficulty passing stools. Although the pain is essentially gone and appetite is satisfactory, patient continues to experience difficulty avoiding. Urinalysis showed 10-20 epithelial cells but no white cells and no bacteria.Graim stain from the cervix revealed rare diplococci which were all extracellular. A culture failed to reveal any gonorrhea. DISCHARGE DISPOSICIAN: Patient will be discharged at the present time on a normal diet. I will ask patient to make an appointment in my office in 48 hours for followup examination to see if she can be released for work the following Monday. Health Science Science Nursing Hit 244 Share QuestionEmailCopy link Comments (0)

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