Example of Medical Report

Topics: Hypertension, Asthma, Cardiology Pages: 6 (941 words) Published: June 18, 2013
Student Name
HCA/220
April, 28 2013
Medical Report Assignment

PAITENT NAME: Smith, John
HOSPITAL NUMBER: 859-656-6561
DATE OF ADMISSION: July, 23 20xx
|Chapter 3 – Medical Record | |History of Present Illness | |The patient arrived, complaining of chronic abdominal pain, vomiting, and feeling exhausted. | | | | | |Past Medical History | |The patient had been having some upper abdominal pain for sometime, and then, it escalated to vomiting along with a fever. Records | |indicate that he had gallstones removed approximately two years ago. | |Physical Examination | |The patient is stooped over and has dry heaving from nausea. He looks sick, sweaty, has a fast pulse (120 beats a minute), and | |shallow, rapid breathing. | | | |Diagnostic/Lab Results | |A blood test was given to the patient. We found an increase of amylase in the blood. The patient's skin was also yellowish - | |jaundice. The abdominal area is purple; pancreatic fluid is leaking due to inflammation. | |Impression/Discussion | |Pancreatitis is a disease where the pancreas becomes inflamed. Pancreatic damage occurs when the digestive enzymes are activated | |before they are secreted into the duodenum and begin attacking the pancreas. The patient will receive treatment in the hospital to | |allow the pancreas to heal. The patient will receive intravenous (IV) fluids to replace lost fluids and maintain their blood | |pressure. The patient will also receive medicines to control pain until the inflammation goes away. Surgery will be performed to | |remove the gallbladder to mitigate any other pancreatic attacks. | | | |Two Questions for prospective hires | |What quadrant of the body can the pancreas be found in? | |Right-upper quadrant. | |If someone had pancreatitis, the fluid that secrets from the pancreas due to inflammation would cause the patient's abdominal skin | |area to turn which color? | |Purple. | |References...

References: |
|Electrocardiogram, (2013), Retrived April 27, 2013 from |
|http://www.nlm.nih.gov/medlineplus/ency/article/003868.htm |
| |
|Medical Language (Second Edition, pages 142-144, 196, & 261-263) by Susan Turley. Published |
|by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. |
| |
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