Medical Record 4.3 page 104
How old is Mr. Marsi?
Where was the treatment rendered?
Does not say
List the three elements of the patient’s complaint
Dizziness for 3 weeks, Headaches for 5-6 weeks, and numbness in left leg and hand
In your own words, not using medical terminology, briefly summarize Mr. Marsi’s history:
51 year old male who has severe health problems
Which of the following is not mentioned at all in this history? (Circle your answer choice.) a.
the prescription medication Mr. Marsi takes
Mr. Marsi’s smoking habit
Mr. Marsi’s activity level at work
Mr. Marsi’s consumption of alcohol
Dr. Spaulding and Mr. Marsi talked at length about Mr. Marsi’s symptoms and how they’ve changed recently, and then Dr. Spaulding examined him. List three objective findings she noted in this examination. (Any three of the following are acceptable.)
T 98.7 and P 76
Dr. Spaulding’s assessment is that he has ________Hypertension_____________________. But she
also wants to make sure Mr. Marsi does not have ____Congestive heart failure______________
Dr. Spaulding’s treatment plan involves four areas. List the specific plan(s) for each of these.
Diagnostic tests ordered:
Chest x –ray, Electrocardiogram
Instruct patient to change (and how) three personal habits:
Decrease smoking, Decrease fat and cholesterol in diet
Increase exercise to 3 times a week for 20-30 mins
Drug prescribed (and how much and when):
Procardia XL 30 mg my mouth daily
Future diagnostic check and/or action to take:
Recheck Blood pressure
When is Dr. Spaulding expecting to see Mr. Marsi again?
In a week
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