(SOLVED) Practice Sheet 5 W-MT (written 5)

Discipline: Nursing

Type of Paper: Essay (any type)

Academic Level: Undergrad. (yrs 3-4)

Paper Format: APA

Pages: 1 Words: 254


Practice Sheet 5 W-MT (written 5)

Convert the below dictated lines into Preoperative History and Physical Report transcription with appropriate format of chart note including headings and all the rules of chart note transcription

the sixty seven year old gentleman underwent ultrasound guided needle biopsy of the prostate during the trans rectal ultrasound a positive bladder mass was noted

he is now to undergo a cystoscopy for confirmation

current medications includes cardura four milligram by mouth every hour multiple vitamins Aspirin, lipitor

  • allergies plant pollen

  • past medical history hypertension

  • past surgery transectomy and removal of lymphoma

  • physical examination he appears well alert and oriented

  • vital signs blood pressure one sixty seven over seventy nine pulse seventy respiration eighteen

  • lungs clear

  • heart rhythm is regular without murmur

  • abdomen soft without masses or tenderness

  • groin is normal.

  • extremities no peripheral edema

  • digital rectal exam(DRE) the prostate was smooth with benign consistency

  • diagnosis possible bladder tumor


Converting the given details into a preoperative history and physical report,

  • step 1

Patient Name :

Date :

Age : 67

Sex : Male

MR# ; ( Insert medical record number )

Chief Complaints:

- Positive bladder mass noted during ultrasound guided needle biopsy of the prostate

History of Present Illness:

- The patient underwent ultrasound guided needle biopsy of the prostate, during which a positive bladder

mass was found.

- He is now scheduled to undergo a cystoscopy for confirmation


- Cardura 4mg, Orally every hour.

- Multiple Vitamins

- Aspirin

- Lipitor


- Plant pollen

Past Medical History:

- Hypertension

Past Surgical History:

- Transectomy and removal of lymphoma

Physical Diagnosis:

- General: The patient appears well, alert, and oriented.

- Vital signs: Blood pressure of 167/79 mmhg, pulse of 70 beats per minute, and respiratory rate of 18

breaths per minute

- Lungs: Clear

- Heart: Rhythm is regular without murmur

- Abdomen: Soft, without masses or tenderness

- Groin: Normal

- Extremities: No peripheral edema

- Digital Rectal Screening: The Prostate was smooth with a benign consistency


- Possible bladder tumor


( insert physician name )

( insert physician signature)