Medical report

Topics: Hypertension, Medical history, Anemia Pages: 4 (764 words) Published: July 20, 2014

Chapter 3 – Medical Record
History of Present Illness
Patient- 33 year old female was brought into ER with severe burning abdominal pain, nausea, and diarrhea. Patient has regurgitated once, light red in color. Patient stated that she has had pain several days, which she has been able to control with OTC-Ranitidine 75mg. This evening pain was worse and nothing was able to ease it. Patient is heavy smoker- 2 packs a day and an occasional drinker- 1-4 drinks a month. Possible pregnancy-2 months.

Past Medical History
Patient was diagnosed in 2010 with GERD and has damage to esophagus as a result.

Physical Examination
Patient is pale, perspiring profusely, and doubled over in pain. BP-178/87
Pulse- 90
Temperature- 100.4
Patient has some tenderness in RLQ

Diagnostic/Lab Results
CBC- elevated white blood count, slight anemia.
ELISA- positive for H-Pylori
Pregnancy test- negative

Admitting patient for possible Peptic Ulcer, ordering Upper gastrointestinal series. Want endoscopy performed to check status of damaged esophagus from previous GERD diagnosis.

Two Questions for prospective hires
Do you think patient is a candidate for Esophageal cancer due to the prior damage of the esophagus? What are the chances of the patient’s ulcer healing, if she refuses to quit or cut back on smoking and the occasional drinking?


Chapter 4 – Medical Record
History of Present Illness

31 year old male patient has been evaluated by me on 9/1/2013 complaining of severe pain in all four quadrants of the abdominopelvic area, ventral and dorsal. Painful urination, with persistent urge to urinate. Patient is nauseated

Past Medical History

Patient has had past medical history of kidney stones most...

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