Medical Records
Chapter 3 – Medical Record | History of Present Illness | Patient is a 35 year old male complaining of nausea, pyrosis, indigestion, and melena stool. Patient stated that he has been experiencing abdominal pain that wakes him in the middle of night for over a month. He stated that he normally can drink a glass of milk or baking soda water to relive the pain, but this has no longer been effective. | Past Medical History | Patient is a smoker who drinks daily and suffering from obesity. Patient uses NSAID’s daily for pain. | Physical Examination | T-98.7 P-80 R-18 BP-140/90. Abdominal pain in the Epigastric region with bloating and tenderness in the umbilical region. | Diagnostic/Lab Results | Labs drawn and patient given CLO test and sent home with fecal occult test. Results of CLO where negative, however fecal occult tests were positive. Preformed endoscopy where there were findings of ulcers on the duodenum and stomach. | Impression/Discussion | Peptic ulcer diseaseA discussion was carried out with the patient of necessary lifestyle changes such as quitting smoking, limit alcohol intake, avoiding spicy foods and to stop using NSAID’s in order to properly treat PUD. The patient was prescribed PPI and asked to return in four weeks for a follow up. | Two Questions for prospective hires | Do you think the patient’s daily use of NSAID’s caused the PUD?Why were the results of CLO test so important? | References | Mayo Clinic . (2012). Retrieved from http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-and-diagnosisMedicine Net . (2012). Retrieved from http://www.medicinenet.com/peptic_ulcer/article.htm |
Chapter 4 – Medical Record | History of Present Illness | Patient is a 64 year old Caucasian female complaining of cough, pyrexia, dyspnea, and fatigue for over a week. | Past Medical History | Patient has a past medical history of asthma, pneumonia and COPD. Patient is currently taking Atrovent
Chapter 4 – Medical Record | History of Present Illness | Patient is a 64 year old Caucasian female complaining of cough, pyrexia, dyspnea, and fatigue for over a week. | Past Medical History | Patient has a past medical history of asthma, pneumonia and COPD. Patient is currently taking Atrovent
References: | Turley, S. (2007). Medical language . Retrieved from The University of Phoenix eBook Collection database. |