Chapter 3 Medical Field Report

Chapter 3 – Medical Record
Patient Name: Johnny Porter
Patient Hospital Number: 00000054545
Patient Date of Admissions: 1/2/2012
History of Present Illness

Patient is 63 year old African American/Black male. Patient was brought in emergency department. The patient wife said he has been complaining of unusual stomach pains. According to the patients wife before bringing him in to the emergency room he was vomiting blood.

Past Medical History

According to the wife he has a history of peptic ulcers disease. According to past medical records the patient has history of past drug abuse. The patient wife

Physical Examination
The patient is sitting up in the bed complaining of stomach pain. The
The patient was transported from home by her daughter-n-law. According to patient daughter-n-law she has been complaining of pains in her right leg approximately one day. Family administered daily pain medications that did not help the condition of her persisting pain. After pain persisted daughter in law later brought the patient in to the emergency room for examination.

Past Medical History

Patient passed medical history was received from hospital records and daughter in law. Patient has history of congestive heart failure, serosis of the liver, kidney disease and hepatitis. The Patient has a history of poor blood circulation which led to her left legs being previously amputated. According to patient daughter in law two surgery where done for amputation. Patient first surgery was down to amputate below the knee. According to daughter-n-law the second surgery of her knee was done to amputate leg above the knee because poor circulation still persists after first amputation. According to daughter-n-law patient is set to dialyze three times per week for treatment of her kidney disease. The patient missed her dialyses treatment