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Edna's Medical Case Summary

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Upon taking Edna’s medical history, Shelia needs to successfully chart Edna Helm’s presenting symptoms, Sheila can follow the six C’s charting guidelines, which are Client’s own words, clarity, completeness, conciseness, chronological, and confidentiality. Starting with the date, Shelia needs to include the Edna’s own words when charting her presenting symptoms. She has to use clarity when documenting information by using proper medical terminology, spelling, and abbreviations. Completeness which is important for all Edna’s information recorded in the medical record. The entry must have a more professional and time-saving image, the order of the information is crucial and is mandatory in all parts of patient care. Edna’s chart should be presented as such, 02/22/YY 4:41 P.M. CC: “I’m always short of breath, and I perspire all the time. I guess I’m gaining weight, but the funny thing is that only my legs seems heavier. My heart is pounding when I lie down at night; it …show more content…
The conditions are Positive Babinski sign, allergic rhinitis, aortic insufficiency, ascites, gastritis, osteoarthritis. Babinski sign is a reflex test that determines lesions and abnormalities in the nervous system, the Babinski reflex is positive when the big toe extends rather than flexes when the lateral sole of the foot is stroked. Allergic rhinitis is the inflammation of nasal mucosa that results in nasal congestion, rhinorrhea, sneezing, and itching of the nose. Aortic insufficiency is a failure of the aortic valve to completely close resulting in blood leaking back into the left ventricle and inefficient heart rate action. Ascites is the accumulation of fluid in the peritoneal cavity and gastritis is the inflammation of the stomach that can cause pain, nausea, tenderness, and vomiting. Osteoarthritis is a common type of arthritis that result from years of wear and tear on

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