Overview: Your final project for this course will be a patient record analysis. You will apply the knowledge of anatomy, physiology, and pharmacology that you have developed during this course in a thorough review of existing patient information in the Final Project Patient File. Specifically, you will review a patient’s history and a discharge chart from a recent physician visit, explaining the reasons behind diagnosis (or diagnoses) based on documented symptoms, citing any inconsistencies or concerns, and discussing the potential and current treatments, all in preparation for your future coding practices.

For this milestone, you will review the patient history file and discuss what it tells you. Discriminating between signs and symptoms, primary diagnoses, secondary diagnoses, and differential diagnoses, discuss what the findings are.

Specifically, the following critical elements must be addressed:

I. Patient History Analysis

a) Summarize the patient history, explaining key patient demographics and family history that could be risk factors for common diseases.

b) 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?

c) Discuss the symptoms the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?

d) What alternate diagnosis (or diagnoses) could these symptoms have indicated? Explain using evidence-based resources to support your

conclusions.

e) 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?

f) Identify the past prescribed medications the patient is taking and explain the purposes of their larger pharmacological groupings.

g) 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.

h) Illustrate how these medications impact the body and its functions. Use examples to support your explanations.

Rubric

Guidelines for Submission: This milestone should be at least 2 pages in length and submitted as a Word document. All sources should be in APA format.

Instructor Feedback: This activity uses an integrated rubric in Blackboard. Students can view instructor feedback in the Grade Center. For more information, review these instructions.

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