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Medical Reports

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Submitted By jaksn06
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Associate Level Material
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 61 year old female. The patient is complaining that they feel weak, their urine is dark, nausea, and they have Jaundice.

Past Medical History

Mrs. Smith has suffered from seizures since she was 18 years old. She has been taking Dilantin to help keep the seizures under control. No other past medical history.

Physical Examination

Temperature is 99.2, pulse rate is at 80, blood pressure 120/85. Mrs. Smith has Jaundice in both eyes. Patient’s abdomen is swollen.

Diagnostic/Lab Results

Labs drawn in emergency room and it showed patient does not have Viral Hepatitis, or Cirrhosis.

Impression/Discussion
Chronic Liver Disease

A discussion was carried out with the patient on starting a healthy diet and getting proper rest. Prescribed antibiotics for the infection, steroids for the inflammation and diuretics to reduce fluid backup.

Two Questions for prospective hires

(1)-Do you think taking the Dilantin over the years caused the Liver Disease?
(2).Do you think this patient will have to worry about deterioration of brain function?

References

Chapter 4 – Medical Record
History of Present Illness

The patient is a 66 year old male complaining of chest pains, coughing up blood, running a fever, fatigue, and real bad cough.

Past Medical History The patient has worked outdoors for over 40 years and, has smoked two packs of cigarettes a day. The patient was, diagnosed with an Ulcer 10years ago.

Physical Examination

Patient is running a temperature of 102. The patient was expectoration, and hemoptysis. The patient was also bradypnen. The breathing was seven breaths pre minute.

Diagnostic/Lab Results

The patient was given an x-ray and an CT scan.

Impression/Discussion

Lung Cancer and Pneumonia

Two Questions for prospective hires

References

Chapter 5 – Medical Record
History of Present Illness

Past Medical History

Physical Examination

Diagnostic/Lab Results

Impression/Discussion

Two Questions for prospective hires

References

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