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💥Perle Labs hầu như luôn mang đến những điều thú vị cho chúng ta phải ko! Tuần này với những câu hỏi vô cùng vô cùng khó , nhưng cũng ko làm nhiệt huyết dành cho @PerleLabs giảm đi .. thậm chí còn tăng nhiều hơn nữa ..
☘️Và đây .. sau cả buổi uống hết 2 chai nước 😆, thì Mỹ cũng đã xong đáp án cho task Clinical Documentation Error Detection Quest .
Có thiếu sót gì thì ace mình comment bên dưới cho Mỹ biết để bổ sung nha !
1. Emergency Department Note: 22-year-old:
Wrist sprain. Plan: RICE protocol (rest, ice, compression, elevation). Ibuprofen 400mg TID PRN. Return for re-evaluation only if symptoms worsen. No immobilization needed.
2. Admission Note: 25-year-old female:
Admit to floor
3. Emergency Department Note: 30-year-old:
Start levetiracetam 500mg IV for seizure prophylaxis
4. Admission Note: 34-year-old male:
admit to surgical ICU for observation and non-operative management
5. Emergency Department Note: 35-year-old:
Start warfarin 5mg daily
6. Admission Note: 40-year-old male:
Subarachnoid hemorrhage ruled out by negative CT
7. Prescription Note: Patient: 42-year-old:
Levofloxacin 750mg daily for 5 days
8. Admission Note: 45-year-old female:
trimethoprim-sulfamethoxazole DS BID
9. Discharge Summary: 45-year-old female:
ciprofloxacin 500mg BID and metronidazole 500mg TID for 7 days
10. Progress Note: 48-year-old female:
Labs within acceptable limits
11. Operative Note: Procedure: Colonoscopy: ( có dòng 50 years old đó ):
Recommend repeat colonoscopy in 10 years per guidelines
12. Admission Note: 52-year-old female:
Monitor with daily chest X-rays
13. Discharge Summary: 54-year-old female:
Lumbar spine precautions reviewed
14. Progress Note: 55-year-old male:
Recheck uric acid and CBC in 6 weeks
15. Progress Note: 56-year-old female:
No need for hepatitis B monitoring during treatment
16. Discharge Summary: 60-year-old male:
resume normal diet including alcohol in moderation once feeling better
17. Emergency Department Note: 62-year-old:
Acute anterior STEMI
18. Progress Note: 63-year-old male:
INR today: 1.8. Assessment: Therapeutic anticoagulation on rivaroxaban
19. Discharge Summary: 68-year-old male: metformin 1000mg BID
20. Progress Note: 70-year-old male:
left hip
21. Progress Note: 71-year-old female:
Continue alendronate
22. Discharge Summary: Patient is: ( câu này là 72 years old đó )
SpO2 42% on room air
23. Discharge Summary: 73-year-old male:
oxybutynin 5mg BID
24. Radiology Report: CT Head: ( là câu có 81 years old )
acute left hemispheric stroke
25. Operative Note: Procedure: Right:
left inguinal canal
26. Progress Note: Patient presents:
Primary hypothyroidism, consistent with lab findings showing suppressed TSH and low free T4
27. Operative Note: Procedure: Cesarean:
14.2 pounds
28. Operative Note: Procedure: Laparoscopic:
The appendix was visualized and appeared normal
29. Operative Note: Procedure: Right:
complex tear of the lateral meniscus posterior horn
30. Progress Note: Assessment: Atrial:
apixaban 50mg BID
31. Operative Note: Procedure: Left:
right sternocleidomastoid muscle
32. Admission Note: 7-year-old male:
Amoxicillin 500mg TID for 10 days
33. Admission Note: Patient is: ( câu này có 58 years old đó nha )
IV amoxicillin-clavulanate 875mg q12h
34. Admission Note: 83-year-old male:
haloperidol 2mg BID standing
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