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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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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[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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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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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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The Emergency Department (ED) nurse is unlike any other. The population in the ED is highly diversified by both age and disease process. The ED cares for all ages and populations across a broad spectrum of disease‚ injury prevention and life-saving measures. For example‚ a person can come in unconscious‚ the next with an earache. The scope of emergency nursing practice encompasses the standard nursing process: assessment‚ diagnosis‚ treatment‚ and evaluation. In addition‚ emergency nursing practice
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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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Emergency Department Triage Triage is an essential element of providing care to patients who present at a hospital emergency department. Triage is defined as a brief clinical assessment that determines the time and sequence in which patients should be seen in the emergency department. During triage‚ an emergency department nurse interviews a patient or the patient’s representative about the medical problem causing concern‚ makes a brief evaluation of the patient‚ and takes the patient’s vital signs
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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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