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Medical Report

This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook. Each medical record should be completed and contain two questions you would ask of the potential hires.

The following suggestions will help you get started:

• Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis.

• For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history.

• For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness.

• For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam.

• For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis.

• For the Impression/Discussion, indicate the patient diagnosis and what the plan is for his or her. This includes treatment, preventative measure to take, or follow-up.

Templates provided on the following pages.

Use the following templates for the assignment. Complete each section, save, and then submit as an attachment.

|Chapter 3 – Medical Record |
|History of Present Illness |
| |
|The patient is a 26-year old male who has experienced mild rectal bleeding two days before admission. He has stated that over the |
|last two days he has had an urge to defecate so he has been rushing to the restroom non-stop. Today, the urgencies were too severe |
|so he reported to the emergency room to be seen. |
| |
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|Past Medical History |
|The patient’s medical history contains a few broken bones. A history of allergy illness due to eating peanuts. The patient was |
|presumed healthy up until this point. |
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|Physical Examination |
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|Temperature 99.8, pulse 91, respiratory rate 40, blood pressure 141/91. Patient is settled in bed. With complaints of being |
|uncomfortable. The abdomen is tender. The patient has had blood in his stools and blood was also found during the digital rectum |
|exam. Patient looks pale. Immediate family has history of Ulcerative Colitis. |
| |
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|Diagnostic/Lab Results |
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|Definitive diagnosis will require a Colonic Mucosal Biopsy. Occult blood in stool; WBC in stool. Leukocytosis during acute |
|exarcerbation. Decreased serum K, Na CI - due to diarrheal loss. Decreased serum albumin due to loss of protein from the diseased |
|bowel wall; the degree of hypo-albuminaemia parallels the severity of the disease. |
| |
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|Impression/Discussion |
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|Ulcerative Colitis |
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|Two Questions for prospective hires |
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|What are some other body systems and whether you have symptoms such as joint pain, eye problems, or skin rash? |
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|Does your family have any history of similar symptoms? |
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|References |
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|Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. |
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|www.medicinenet.com/ulcerative_colitis |
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|Chapter 4 – Medical Record |
|History of Present Illness |
|The patient is a 25-year old female who has complained of shortness of breath. Over the last week, she has had a sharp pain in her |
|chest, arm and shoulder. The patient came in today because she had a cough with bloody sputum. |
| |
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| |
| |
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|Past Medical History |
|The patient is an obese female with a history of asthma. Has also had a history of heart problems and in the past has had a |
|catheter placement. |
| |
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|Physical Examination |
|Temperature 100.6, pulse 88, respiratory rate 41, blood pressure 139/87. Patient has been admitted and is settled in bed with mild |
|discomfort. She is considered to have a moderate clinical likelihood of (PE). Her D-dimer level was elevated and a chest computed |
|tomography scan with contrast demonstrated a right main pulmonary artery embolus. |
| |
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|Diagnostic/Lab Results |
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|The patient demonstrates the increased risk of VTE with hormone replacement therapy in an outpatient without other known risk |
|factors. The case also highlights the diagnostic approach of using D-dimer in conjunction with an assessment of clinical |
|likelihood. The elevated D-dimer was appropriately followed with a chest CT that documented PE. The history of progressive, |
|otherwise unexplained dyspnea is the strongest clinical clue. |
| |
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|Impression/Discussion |
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|Acute Pulmonary Embolism |
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|Two Questions for prospective hires |
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|Should thrombolytic therapy be administered? |
|Can the patient be treated as an outpatient? |
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|References |
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|http://my.clevelandclinic.org/disorders/pulmonary_embolism |
| |
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|Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. |
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|Heit JA. The epidemiology of venous thromboembolism in the community: implications for prevention and management. J Thromb |
|Thrombolysis. 2006; 21: 23–29. |
| |

|Chapter 5 – Medical Record |
|History of Present Illness |
|The patient is a 47-year old female who has complained of angina (chest pain or discomfort). Today she has experienced shortness of|
|breath and fatigue. Patient reported to the emergency room due to these symptoms and weakness. |
| |
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| |
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|Past Medical History |
|The patient has a history of diabetes. Diabetes has made her a high risk for heart disease. The patient also has high blood |
|pressure. She is slightly overweight but was put on a strict no carbohydrates or cholesterol diet. She was also a former smoker. |
| |
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|Physical Examination |
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|Temperature 98.9 Blood Pressure 168/98, Pulse 90, Respirations 20. Appears alert, oriented and cooperative. Pupils equally round, 4|
|mm, reactive to light and accommodation, sclera and conjunctiva normal. Fundoscopic examination reveals normal vessels without |
|hemorrhage. |
|Tympanic membranes and external auditory canals normal. Nasal mucosa normal. |
|Oral pharynx is normal without erythema or exudate. Tongue and gums are normal. |
|Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or supraclavicular areas. Trachea is midline and |
|thyroid gland is normal without masses. Carotid artery upstroke is normal bilaterally without bruits. Jugular venous pressure is |
|measured as 8 cm with patient at 45 degrees. Chest: |
|Lungs are clear to auscultation and percussion bilaterally except for crackles heard in the lung bases bilaterally. PMI is in the |
|5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right |
|inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. |
|Cystic changes are noted in the breasts bilaterally but no masses or nipple discharge is seen. No hepatomegaly. |
| |
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|Diagnostic/Lab Results |
|There is little or no CPK activity in the lungs, liver, kidney pancreas, or RBC. Decreased arterial PO2 and oxygen saturation. |
|Increased red blood count. LDH activity is found in almost all human tissues. The liver and skeletal muscle have the greatest |
|concentrations, followed by the heart. |
| |
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|Impression/Discussion |
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|Coronary Artery Disease |
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|Two Questions for prospective hires |
|What is the difference between stable and unstable angina? |
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|Does your family have a history of heart disease? |
| |
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|References |
|http://health.nytimes.com/health/guides/disease/coronary-heart-disease |
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|Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. |
| |
|http://www.imclerkship.umn.edu/ |
| |
| |
| |

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