Patient Medical Record

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ADMISSION HISTORY AND PHYSICAL EXAM

PATIENT NAME: Jan Jenkins
HOSPITAL NUMBER: 013-256-7456
DATE OF ADMISSION: September 23, 2012

HISTORY OF PRESENT ILLNESS
Patient is a 31-year-old caucasian female evaluated by me in the emergency department on the above date, complaining of extreme fatigue, shortness of breath, and headaches.

PAST HISTORY:
The patient was diagnosed with Diabetes 5 years ago and diagnosed with Myelodysplastic Syndrome 8 months ago. Patient has had an appendectomy 15 years ago. She does not smoke or drink alcohol.

PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 100, respiratory rate 42 per minute, temperature 99.1, blood pressure 156/96. GENERAL: The patient appears very tired at the present time. HEENT: negative.
CHEST: There is an increased anteroposterior diaemeter to the chest. No intercostal retractions during inspiration. HEART: Normal heart sounds without murmor or racing.
ABDOMEN: soft and nontender.
EXTREMETIES: normal with full range of motion.

LABORATORY DATA:
Urine test was positive for ketones. A complete blood panel was done and showed a blood sugar level of 150 mg. White blood cell count was elevated at 13.5

IMPRESSION:
Myelodysplastic Syndrome
Diabetes Mellitus

Two questions for potential hires:

What else does this medical report need:
A. more in depth description B. less detail
C. a prognosis plan D. nothing
E. all the above
What else could this report have that will be beneficial to all medical personnel? A. more specific information B. more information on vital
C. a more in depth past history D. all the above
E. nothing more

REFERENCES:

Retrieved from http://1. American Diabetes Association. Standards of medical care in diabetes — 2013. Diabetes Care. 2013;36(suppl):1 /

Retrieved from http://www.cancer.org/cancer/myelodysplasticsyndrome/index

ADMISSION HISTORY AND PHYSICAL EXAM

PATIENT NAME: Cody Jones
HOSPITAL NUMBER: 602-888-6939
DATE OF ADMISSION: June 1, 2012

HISTORY OF PRESENT ILLNESS
This patient is an 18 month old african american male evaluated by me in the emergency department on the above date, patient was very irritable and left ear appears to be red and swollen.

PAST HISTORY
This is the patients third time coming into the emergency department with like symptoms. At age 12 months patient was diagnosed with asthma after a chronic sinus infection and wheezing. Patient has no surgical history.

PHYSICAL EXAMINATION
VITAL SIGNS: pulse 100, respiratory rate 25 per minute, temperature 99.3, blood pressure 95/60. GENERAL: Patient appears to be irritable.
HEENT: Negative,except for redness and swelling of left ear. CHEST: Normal
HEART: Normal heart sounds without murmor.
ABDOMEN: soft and nontender.
EXTREMETIES: normal with full range of motion.

LABORATORY DATA
Complete blood count came back normal.

IMPRESSION
Otis media effusion of the left auditory canal
Asthma

Two questions for potential hires:
Is this a complete medical report:
A. yes B. no, it lacks information
C. It needs more information for vitals D. more information needed for patient past history E. needs a diagnosis

Does the medical report have follow up care information:
A. It has just enough information B. has to little information No follow up care information is needed D. follow up care does not go on a medical record E. Medical record should have detailed specific follow up information

References
Kids Health. (2013). Retrieved from http://kidshealth.org/parent/medical/asthma/wheezing_asthma.html#

emedicine health. (2013). Retrieved from http://www.emedicinehealth.com/pediatric_vital_signs/article_em.htm

American Academy of Pediatrics. (2013). Retrieved from http://pediatrics.aappublications.org/content/113/5/1412.full

ADMISSION HISTORY AND PHYSICAL EXAM

PATIENT NAME: Fred Thompson
HOSPITAL NUMBER:...
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