Medical Records
Chapter 3 – Medical Record
History of Present Illness
The patient is a 61 year old female. The patient is complaining that they feel weak, their urine is dark, nausea, pain in the abdomen.
Past Medical History
Mrs. Carter has suffered from seizures since she was 14 years old. She has been taking Dilantin to help keep her seizures under control and to a minimum. Clear history otherwise.
Physical Examination
Temperature was 99.8
Pulse was 83
Blood Pressure was 120/84
Abdomen area was swollen and sore to touch.
Diagnostic/Lab Results
Patient was sent to lab to have blood drawn which did not show any viral infections anywhere within the body.
Impression/Discussion
Chronic Liver Disease
Dietician was sent to patients room to discuss healthier diet and exercise as well as rest. Doctor prescribed medication for the abdominal inflammation.
Two Questions for prospective hires
1. Could the Dilantin that Mrs. Carter has taken for the seizures caused the Liver Disease?
2. What are other ways could this liver problem come up and why?
References
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc
Chapter 4 – Medical Record
History of Present Illness
Patient is a 58 year old male suffering from severe chest pains, hard coughing with blood in their mucus, fever, and fatigue.
Past Medical History
Patient smokes consistently everyday for the past 23 years, has worked in a shop since he was 18 years old. Was diagnosed with an Ulcer 10 years ago at the age of 33.
Physical Examination
Fever of 101.8. Patient was Hemoptysis at arrival. Was having a low amount of breaths per minute.
Diagnostic/Lab Results
An X-Ray and a CT Scan were completed while admitted.
Impression/Discussion
Lung Cancer
Pneumonia
Steroids were prescribed for the Pneumonia along with an antibiotic. Patient was admitted to hospital for three days to watch Pneumonia and breathing. Breathing
History of Present Illness
The patient is a 61 year old female. The patient is complaining that they feel weak, their urine is dark, nausea, pain in the abdomen.
Past Medical History
Mrs. Carter has suffered from seizures since she was 14 years old. She has been taking Dilantin to help keep her seizures under control and to a minimum. Clear history otherwise.
Physical Examination
Temperature was 99.8
Pulse was 83
Blood Pressure was 120/84
Abdomen area was swollen and sore to touch.
Diagnostic/Lab Results
Patient was sent to lab to have blood drawn which did not show any viral infections anywhere within the body.
Impression/Discussion
Chronic Liver Disease
Dietician was sent to patients room to discuss healthier diet and exercise as well as rest. Doctor prescribed medication for the abdominal inflammation.
Two Questions for prospective hires
1. Could the Dilantin that Mrs. Carter has taken for the seizures caused the Liver Disease?
2. What are other ways could this liver problem come up and why?
References
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc
Chapter 4 – Medical Record
History of Present Illness
Patient is a 58 year old male suffering from severe chest pains, hard coughing with blood in their mucus, fever, and fatigue.
Past Medical History
Patient smokes consistently everyday for the past 23 years, has worked in a shop since he was 18 years old. Was diagnosed with an Ulcer 10 years ago at the age of 33.
Physical Examination
Fever of 101.8. Patient was Hemoptysis at arrival. Was having a low amount of breaths per minute.
Diagnostic/Lab Results
An X-Ray and a CT Scan were completed while admitted.
Impression/Discussion
Lung Cancer
Pneumonia
Steroids were prescribed for the Pneumonia along with an antibiotic. Patient was admitted to hospital for three days to watch Pneumonia and breathing. Breathing