Medical Report

Topics: Pneumonia, Coronary artery disease, Angina pectoris Pages: 4 (511 words) Published: March 11, 2012
Medical Reports

Chapter 3-

PATIENT NAME- Smith, Robin
HOSPITAL NUMBER-257-439-7154
DATE OF ADMISSION- September 25, 2010

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, and they have Jaundice.

Past Medical History-
Mrs. Smith has suffered from seizures since she was 18 years old. She has been taking Dilantin to help keep the seizures under control. No other past medical history.

Physical Examination-
Temperature is 99.2, pulse rate is at 80, blood pressure 120/85. Mrs. Smith has Jaundice in both eyes. Patient’s abdomen is swollen.

Laboratory Data-
Labs drawn in emergency room and it showed patient does not have Viral Hepatitis, or Cirrhosis.

Impression-
Chronic Liver Disease

Discussion-
A discussion was carried out with the patient on starting a healthy diet and getting proper rest. Prescribed antibiotics for the infection, steroids for the inflammation and diuretics to reduce fluid backup.

Questions-
(1)-Do you think taking the Dilantin over the years caused the Liver Disease? (2).Do you think this patient will have to worry about deterioration of brain function?

Chapter 4

PATIENT NAME- Ross Jim
HOSPITAL NUMBER-567-931-6434
DATE OF ADMISSION- December 12, 2008

History of present illness-
The patient is a 66 year old male complaining of chest pains, coughing up blood, running a fever, fatigue, and real bad cough.

Past Medical History-
The patient has worked outdoors for over 40 years and, has smoked two packs of cigarettes a day. The patient was, diagnosed with an Ulcer 10years ago.

Physical Examination-
Patient is running a temperature of 102. The patient was expectoration, and hemoptysis. The patient was also bradypnen. The breathing was seven breaths pre minute.

Laboratory Data-
The patient was given an x-ray and an CT scan.

Impression-
Lung Cancer and Pneumonia

Discussion-...
Continue Reading

Please join StudyMode to read the full document

You May Also Find These Documents Helpful

  • Recommendation Report Essay
  • Report Writing Essay
  • How do I write a report Essay
  • Essay about Impormal Report
  • Essay on incident report
  • Format of Report Essay
  • Business Report Essay
  • Essay about Siwes Report

Become a StudyMode Member

Sign Up - It's Free