Medical Records Essay

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Medical Records

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 Dilatation 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 Dialectal 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 Dilatation 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 Etalon, by Susan Turkey.

Published by Prentice Hall. Copyright (0 2011 by Pearson Education, Inc Chapter 4 – Medical Record 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 Homeostasis 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 through it without treatment. Two Questions for prospective hires 1. Do you think the smoking caused the cancer in the lung or was it chemicals that were inhaled while working in the shop for so many years? 2. What are some common signs of Pneumonia?