Physical Exam

Medical Reports

12/2/11

The Language of Healthcare

Mrs. J.Bacchus

Karina Rodriguezsouza

History and Physical Examination

Patient Name:           Torres, Michelle

Hospital Medical Chart: 914-406-705

Date of Admission:           June 28,2011

History of Presents Illness

The patient is a 40 year old Hispanic woman who is experience a high severe fever back pain and abdominal pain and lower leg pain on her right side of the body. Last she was had and vomiting and weakness. She has also had a fairly substantial weight loss over the last year or so. She also claims that she gets a lot of stomach and chest pain that maybe it can be pyrosis. She is wrong that she has not got to the bathroom but has blood in her urine that she had to get a blood work and ultra sound. She also states that she had it in the past. Most of the pain is the epigastric area, where she was been receive the pain during rest or eating foods.

Physical Examination
Her vital sign are 98.4 her pulse is 80, respiration 20, BP 115/40 she is stable and oriented at times. Her abdomen is soft and no mass or organomegally. She also as redness looks in the LRQ.

Laboratory Data

Blood was taking in that the Emergency Room and the result are that her hemoglobin 12 and blood cell count of 15. Other blood work within normal limits.   Urinalysis is normal

Impression

Appendicitis

Discussion

There will be a brief discussion with the parent to explain the cause and effect of the treatment the will take place of illness. Once the is discussed we well be doing a appendectomy surgery.

Questions
  1. What would be the cause of this illness was not treat on time?

  2. Her symptoms were more stomach pain   and   not eating well,   would this cause the pain on RLQ to create

History and Physical Examination

Patient Name:       Bella Beltran

Medical Chart:       123-456-78

Date of Admission: 12//22/10

HISTORY OF ILLNESS

The patient is a 3 year old girl... [continues]

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