Preview

Medical Records

Satisfactory Essays
Open Document
Open Document
380 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Medical Records
Chapter 3 – Medical Record
History of Present Illness
The patient is a 61 year old female. The patient is complaining that they feel weak, their urine is dark, nausea, pain in the abdomen.
Past Medical History
Mrs. Carter has suffered from seizures since she was 14 years old. She has been taking Dilantin to help keep her seizures under control and to a minimum. Clear history otherwise.
Physical Examination
Temperature was 99.8
Pulse was 83
Blood Pressure was 120/84
Abdomen area was swollen and sore to touch.
Diagnostic/Lab Results
Patient was sent to lab to have blood drawn which did not show any viral infections anywhere within the body.
Impression/Discussion
Chronic Liver Disease
Dietician was sent to patients room to discuss healthier diet and exercise as well as rest. Doctor prescribed medication for the abdominal inflammation.
Two Questions for prospective hires
1. Could the Dilantin that Mrs. Carter has taken for the seizures caused the Liver Disease?
2. What are other ways could this liver problem come up and why?
References
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc

Chapter 4 – Medical Record
History of Present Illness
Patient is a 58 year old male suffering from severe chest pains, hard coughing with blood in their mucus, fever, and fatigue.
Past Medical History
Patient smokes consistently everyday for the past 23 years, has worked in a shop since he was 18 years old. Was diagnosed with an Ulcer 10 years ago at the age of 33.
Physical Examination
Fever of 101.8. Patient was Hemoptysis at arrival. Was having a low amount of breaths per minute.
Diagnostic/Lab Results
An X-Ray and a CT Scan were completed while admitted.
Impression/Discussion
Lung Cancer
Pneumonia
Steroids were prescribed for the Pneumonia along with an antibiotic. Patient was admitted to hospital for three days to watch Pneumonia and breathing. Breathing

You May Also Find These Documents Helpful

  • Satisfactory Essays

    Dr. J.K. McClain and other members of the cardiology department consulted on the patient. They felt that his hypokinesia and breathlessness were not secondary to his cardiac status. He had supraventricular cardiac arrhythmias, including atrial fibrillation and atrial flutter. The cardiology staff utilized intravenous medications that controlled the cardiac rate, adequately resolving these cardiac issues. I managed the patient’s venerator in the intensive care status along with my respiratory therapy team. Unfortunately the patient developed multiple infections,…

    • 405 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Patrick Platt

    • 413 Words
    • 2 Pages

    GENERAL: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm. Vital signs: Blood pressure 140/90, temperature 98.3 degrees Fahrenheit, pulse 97, respiration 18.…

    • 413 Words
    • 2 Pages
    Powerful Essays
  • Satisfactory Essays

    none

    • 2449 Words
    • 7 Pages

    The patient is a 36 year old male who came to the hospital because of an episode of hematemesis. The patient stated that for the past few days he had had anorexia and epigastric pain, which was worse if he tried to eat. An NG tube was placed and drained a small amount of bright red blood, as well as some coffee-ground material. Hemoccult test showed dark, tarry stool and positive for occult blood. The patient is a 21 year old male who presented with a history of sudden onset of abdominal pain, first generalized, and then localizing to the RLQ. The pain was accompanied with anorexia and nausea. It has become increasingly more severe over the past 3 hours so that the patient now cannot walk. He had one episode of vomiting, and has a low-grade fever of 100. On examination the patient was in acute distress due to pain. Palpation of the abdomen showed generalized tenderness with marked pain in the RLQ and rebound pain. STAT CBC showed leukocytosis of 21,000. Abdominal ultrasound was ordered.…

    • 2449 Words
    • 7 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Death Summary

    • 306 Words
    • 2 Pages

    Dr. J.K. Mc Clain and other members of the cardiology department consulted on the patient. They felt that his hypoxia and breathlessness were not secondary to his cardiac status. He had supraventricular cardiac arrhythmias, including atrial fibrillation and atrial flutter. The cardiology staff utilized intravenous medications that controlled the cardiac rate, adequately resolving these cardiac issues. I managed the patient’s ventilator in intensive care status along with my respiratory therapy team. Unfortunately the patient developed multiple infections, hospital acquired, including Klebsiella pneumonia infection and…

    • 306 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Brenda Seggerman H&P

    • 608 Words
    • 3 Pages

    HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding, more like spotting, over the past month. She denies the chance of pregnancy, although she stated that she is sexually active and using no birth control.…

    • 608 Words
    • 3 Pages
    Satisfactory Essays
  • Better Essays

    Swollen Kidneys

    • 702 Words
    • 3 Pages

    His vital signs are as follows: BP 172/100, heart rate 92 beats per minute, and a temperature of 102.2 F. There have been some labs done. His red blood count is 3.1 million cells, white blood count is 22,000 cells, potassium is 5.4 mEq/L, calcium is 6.8 mg/dL, phosphate is 4.3 mEq/L, urea is 37 mg/dL, creatinine 2.0 mg/dL, albumin is 2.9 mg/dL, and pH is 7.29. With labs like these, more testing was done. A chemistry panel which showed protein 1.7 gm/24 hours, glomerular filtration rate of less than 30 ml/minute, and his urine sediment showed presence of gram negative bacilli, presence of white blood cells, presence of red blood cells, and granular and waxy casts.…

    • 702 Words
    • 3 Pages
    Better Essays
  • Satisfactory Essays

    Epidemology Case Study 3

    • 281 Words
    • 2 Pages

    R.S. has smoked for many years and has developed chronic bronchitis, a chronic obstructive pulmonary disease (COPD). He also has a history of coronary artery disease and peripheral arterial vascular disease. His arterial blood gas (ABG) values are pH = 7.32, PaCO2 = 60 mm Hg, PaO2 = 50 mm Hg, HCO3- = 30 mEq/L. His hematocrit is 52% with normal red cell indices. He is using an inhaled ß2 agonist and theophylline to manage his respiratory disease. At this clinic visit, it is noted on a chest x-ray that R.S. has an area of consolidation in his right lower lobe that is thought to be consistent with pneumonia.…

    • 281 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    R.S. has smoked for many years and has developed chronic bronchitis, a chronic obstructive pulmonary disease (COPD). He also has a history of coronary artery disease and peripheral arterial vascular disease. His arterial blood gas (ABG) values are pH = 7.32, PaCO2 = 60 mm Hg, PaO2 = 50 mm Hg, HCO3- = 30 mEq/L. His hematocrit is 52% with normal red cell indices. He is using an inhaled ß2 agonist and Theophylline to manage his respiratory disease. At this clinic visit, it is noted on a chest x-ray that R.S. has an area of consolidation in his right lower lobe that is thought to be consistent with pneumonia.…

    • 465 Words
    • 2 Pages
    Good Essays
  • Better Essays

    Unit 1 Case Study

    • 910 Words
    • 4 Pages

    R.S. is a long-time smoker who developed bronchitic chronic obstructive pulmonary disease (COPD). He also has a history of coronary artery disease and peripheral vascular disease. His arterial blood gas (ABG) values are pH = 7.32, PaCO2 = 60 mm Hg, PaO2 = 50 mm Hg, HCO3 - = 30 mEq/L. His hematocrit is 52% with normal red cell indices. He is taking an inhaled ß agonist and theophylline to manage his respiratory condition. At his clinic visit, it is noted that R.S. has an area of consolidation in his right lower lobe thought to be consistent with pneumonia.…

    • 910 Words
    • 4 Pages
    Better Essays
  • Satisfactory Essays

    Medical Transcription

    • 659 Words
    • 3 Pages

    SOCIAL HISTORY: Married has one daughter. Patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies ETOH. Smoked marijuana last night. No IV drug abuse.…

    • 659 Words
    • 3 Pages
    Satisfactory Essays
  • Satisfactory Essays

    HISTORY OF PRESENT ILLNESS: I was called to see this 69-year-old black female patient, well known to me, who was brought to the ER after she sustained an injury of her right hip. She states she was walking when her right leg just “gave out”, and she fell on to the right hip. She complained of mild pain in the right hip, and mild edema was noted in the ER. In addition she had external rotation of the right leg. Initial x-ray demonstrated findings of intertrochanteric fracture nondisplaced of the right hip. Consultation was obtained from Dr. Dodd who concurred with the diagnosis and treatment recommendations were made. She was subsequently admitted to the hospital for further evaluation and treatment, including surgical repair of the hip.…

    • 498 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Intestinal obstruction exists when blockage prevents the normal flow of intestinal tract. The obstruction can be partial or complete. Its severity depends on the region of bowel affected, the degree to which the lumen is occluded, and especially the degree which the vascular supply to the bowel wall is disturbed.…

    • 9740 Words
    • 39 Pages
    Powerful Essays
  • Good Essays

    Patient Teaching Paper

    • 3191 Words
    • 13 Pages

    6. Health State: Admitted at 14:36 and appendectomy surgery performed from 19:32 to 20:50 on 10/12/13. Assessment findings: BP 136/83, HR 86, RR 14, O2 Sat 96 on oxygen 2L nasal cannula, Temp 98.4F, abd pain 3/10. Lungs: clear and equal breath sounds; apical pulse: auscultated, strong, regular; pulses: equal, regular, strong radial and pedal sites, no edema. Capillary refill immediate (less than 2 seconds). Negative Homan sign bilaterally. Pt expresses interest in leaving hospital as soon as possible. Labs: last accu-check 18:46 on 10/14/13: BG 114. Soft diet. Weight: 225 lbs. (102 kg); Height: 5’11”; BMI: 31.4 (obese)…

    • 3191 Words
    • 13 Pages
    Good Essays
  • Powerful Essays

    Republic of the Philippines University of Northern Philippines Tamag, Vigan City College of Nursing [pic] A Behavioral Analysis of Undifferentiated Schizophrenia In partial fulfillment Of the requirements Of the subject NCM 105:…

    • 6617 Words
    • 27 Pages
    Powerful Essays