HISTORY AND PHYSICAL EXAMINATION Patient Name: Deanna Martinez ID No.: 117232 Room No.: 425 Date of Admission: 05/26/2013 Admitting Physician: Sheila Goodman‚ MD Admitting Diagnosis: Questionable herniated disk Chief Complain: Low back pain‚ right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain. She said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent
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HILLCREST MEDICAL CENTER HISTORY AND PHYSICAL EXAMINATION Patient Name: Emma Parker Hospital No.: 11259 Room No.: 444 Date of Admission: 09/25/2010 Admitting Physician: Sherman Loyd‚ M.D. Admitting Diagnosis: Acute intertrochanteric fracture of right hip. The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert oriented x3 with reasonable thought content she understood questions
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[pic] HISTORY AND PHYSICAL EXAMINATION (H&P) Patient Name: Brenda Seggerman Hospital No.: N/A Room No.: N/A Date of Admission: 03/27/- - - - Admitting Physician: Alex Mcclure‚ MD Admitting Diagnosis: Ectopic Pregnancy HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. The patient denies the chance of pregnancy‚ although the patient states that she
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Admission: 06/22/…. Admitting Physician: Leon Medina‚ MD Internal Medicine Admitting Diagnosis: Stomatitis possibly methotrexate related. Chief Complaint: Swelling of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago she developed a respiratory infection for which she received antibiotics
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Physical examination Definition A physical examination is the evaluation of a body to determine its state of health. The techniques of inspection include palpation (feeling with the hands and/or fingers)‚ percussion (tapping with the fingers)‚ auscultation (listening)‚ and smell. A complete health assessment also includes gathering information about a person’s medical history and lifestyle‚ conducting laboratory tests‚ and screening for disease. These elements constitute the data on which a diagnosis
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HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 RM #: 541 Date of Admission: 06/22/---- Admitting Physician: Leon Medina MD‚ Internal Medicine Admitting Diagnosis: Stomatitis‚ possibly methotrexate related CHIEF COMPLAINT: Swelling of lip causing difficulty swallowing HISTORY OF PRESENT ILLNESS: This patient is a 57 yr. old‚ Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient
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CASE STUDY 3 HISTORY AND PHYSICAL EXAMINATION Patient Name: Putul Barua Patient ID: 135799 Room No.: CCU-4 Date of Admission: 01/07/2013 Admitting Physician: Simon Williams‚ MD Admitting Diagnoses 1. Rule out myocardial infraction 2. History of tuberculosis. 3. Hemoptysis. 4. Status post embolectomy. CHIEF COMPLAINT: Tightness in the chest‚ shortness of breath‚ fast heart rate. HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42-year-old gentleman from Bangladesh
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HISTORY AND PHYSICAL EXAMINATION_______________________ Patient Name: Chapman Robert Kinsey Patient ID: 110589 Room No.: 322-B Date of Admission: 23 February ---Admitting Physician: Martha C. Eaton‚ MD‚ Geriatrics Chief Complaint: Admitted from Dr. Max Hirsch’s office due to deep ulcer on left toe. Admitting Diagnoses 1. Severe peripheral vascular disease‚ status post deep ulcer on left toe. Rule out thrombolysis. The patient was admitted to a regular floor. Condition is serious. 2. ALLERGY TO PENICILLIN
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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Putul Barua Patient ID: 135799 Age: 42 Sex: M Room No.: CCU4 Date of Admission: 01/07/---- Admitting Physician: DR. Simon Williams‚ MD Chief Complaint: Tightness in the chest‚ shortness of breath‚ fast heart rate. ADMITTING DIAGNOSIS 1) Rule out myocardial infarction 2) History of TB 3) Hemoptysis 4) Status post embolectomy HISTORY OF PRESENT ILLNESS: Mr.
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HISTORY AND PHYSICAL EXAMIATION OR EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 Room No.: Date of Admission/ Date of Arrival: 3/27 Admitting/ Attending Physician: Alex McClure‚ MD Admitting Diagnosis: Ectopic Pregnancy Chief Complaint: Lower Abdominal Pain HISTORY OF PRESENT ILLNESS: The patient states that she has been having some vaginal bleeding‚ more like spotting over the past month. She denies the chance of pregnancy although she states
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