Patient Medical Record free essay sample

VITAL SIGNS: Pulse 100, respiratory rate 42 per minute, temperature 99. 1, blood pressure 156/96. GENERAL: The patient appears very tired at the present time. HEENT: negative. CHEST: There is an increased anteroposterior diaemeter to the chest. No intercostal retractions during inspiration. HEART: Normal heart sounds without murmor or racing. ABDOMEN: soft and nontender. EXTREMETIES: normal with full range of motion. LABORATORY DATA: Urine test was positive for ketones. A complete blood panel was done and showed a blood sugar level of 150 mg. White blood cell count was elevated at 13. 5 IMPRESSION: Myelodysplastic Syndrome Diabetes Mellitus Two questions for potential hires: What else does this medical report need: A. more in depth description B. less detail C. a prognosis plan D. nothing E. all the above What else could this report have that will be beneficial to all medical personnel? A. more specific information B. more information on vital C. a more in depth past history D. We will write a custom essay sample on Patient Medical Record or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page all the above E. nothing more REFERENCES: Retrieved from http://1. American Diabetes Association. Standards of medical care in diabetes — 2013. Diabetes Care. 2013;36(suppl):1 / Retrieved from http://www. cancer. org/cancer/myelodysplasticsyndrome/index ADMISSION HISTORY AND PHYSICAL EXAM PATIENT NAME: Cody Jones HOSPITAL NUMBER: 602-888-6939 DATE OF ADMISSION: June 1, 2012 HISTORY OF PRESENT ILLNESS This patient is an 18 month old african american male evaluated by me in the emergency department on the above date, patient was very irritable and left ear appears to be red and swollen. PAST HISTORY This is the patients third time coming into the emergency department with like symptoms. At age 12 months patient was diagnosed with asthma after a chronic sinus infection and wheezing. Patient has no surgical history. PHYSICAL EXAMINATION VITAL SIGNS: pulse 100, respiratory rate 25 per minute, temperature 99. 3, blood pressure 95/60. GENERAL: Patient appears to be irritable. HEENT: Negative,except for redness and swelling of left ear. CHEST: Normal HEART: Normal heart sounds without murmor. ABDOMEN: soft and nontender. EXTREMETIES: normal with full range of motion. LABORATORY DATA Complete blood count came back normal. IMPRESSION Otis media effusion of the left auditory canal Asthma Two questions for potential hires: Is this a complete medical report: A. yes B. o, it lacks information C. It needs more information for vitals D. more information needed for patient past history E. needs a diagnosis Does the medical report have follow up care information: A. It has just enough information B. has to little information No follow up care information is needed D. follow up care does not go on a medical record E. Medical record should have detailed specific follow up inform ation References Kids Health. (2013). Retrieved from http://kidshealth. org/parent/medical/asthma/wheezing_asthma. html# emedicine health. (2013). Retrieved from http://www. medicinehealth. com/pediatric_vital_signs/article_em. htm American Academy of Pediatrics. (2013). Retrieved from http://pediatrics. aappublications. org/content/113/5/1412. full ADMISSION HISTORY AND PHYSICAL EXAM PATIENT NAME: Fred Thompson HOSPITAL NUMBER: 557-852-3685 DATE OF ADMISSION: April 6, 2013 HISTORY OF PRESENT ILLNESS This 78-year-old caucasian was evaluated by me in the emergency department on the above date, complaining of progressive shortness of breath, fever, fatigue, heartburn, and upper back pain. PAST HISTORY The patient has a history of myocardial infarction. 2 years ago patient had like symptoms and was diagnosed with myocardial infarction after results were positive from a electrocardiogram (ECG). Patient also has gout. Does not smoke or drink alcohol. No past surgical history. PHYSICAL EXAMINAION VITAL SIGNS: Pulse 90, respiratory rate 52 per minute, temperature 101. 1, blood pressure 154/96. GENERAL: The patient appears to be fatigued and is sweaty from fever at this time. HEENT: Negative. CHEST: There is an increased anteroposterior diameter to the chest. HEART: The heart appears to have a skipped beat. ABDOMEN: Soft and nontender. EXTREMETIES: Patient has full range of motion. Both ankles have swelling . LABORATORY DATA Complete blood count shown an elevated white blood cell count of 16,4000. Blood count also shown cardiac enzymes to be present. Uric acid was also elevated and present in blood count. A urine test shown positive for uric acid. IMPRESSION Congestive heart failure Myocardial Infarction Gout Two questions for potential hires: Is this a complete medical report: A. yes B. no, it lacks information C. It needs more information for vitals D. more information needed for patient past history E. needs a diagnosis What other information is needed on this report: A. more lab results B. specific lab results more patient history D. more information on physical examination E. all the above References WebMD. (2013). Retrieved from http://arthritis. webmd. com/tc/gout-topic-overview MedicineNet. (2013). Retrieved from http://www. medicinenet. com/heart_attack/page6. htm LabTestsOnline. (2013). Retrieved from http://labtestsonline. org/understanding/analytes/uric-acid/tab/test