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Medical Report Essay Sample

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Medical Report Essay Sample

Past Medical History

According to the wife he has a history of peptic ulcers disease. According to past medical records the patient has history of past drug abuse. The patient wife

Physical Examination
The patient is sitting up in the bed complaining of stomach pain. The patient stomach looks to be swollen. The patient skin around his mid area of the body is decolorized.

Diagnostic/Lab Results
The patient was taken in for immediate blood work and x-rays. The patient heart rate pulse. The lab result revealed that patient has cancerous tumors of the stomach which begun in glands in the gastric mucosa. Cancer was developed due to chronic irritation from a helicobacterpylori infection.

Impression/Discussion
The patient referred by the healthcare professional to undergo immediate surgery. The surgery will be to remove the cancerous tumors and part of the stomach gastrectomy.

Two Questions for prospective hires
What could have cause the patent to develop cancerous tumors of the stomach?
Should a patient with ulcers continue to take aspirin medication products?

References

Chapter 4 – Medical Record
Patient Name: Carlon Wilson
Patient Hospital Number: 44587987
Patient Date of Admission: 1/3/2010
History of Present Illness
The patient is a 45 year old Asian female. The patient was brought in through emergency ambulance. The patient is complaining of fever, heavy coughing and dizziness.

Past Medical History
According to patient caregiver the patient has a history of chronic obstructive pulmonary disease.

Physical Examination
Patient is sitting on the bed continuously coughing. The patient is experiencing abnormal breathing, sounds of wheezing

Diagnostic/Lab Results
The patient is taking for blood work. The blood work determined that the patient is experiencing a common head cold and an upper respiratory infection.

Impression/Discussion
Patient is informed by the physician to get numerous about or rest until symptoms clear. Patient is also given antibiotics as a means of treatment for common cold and upper respiratory infections.

Two Questions for prospective hires
What is a upper respiratory infection?
Why is blood work necessary

References

Chapter 5 – Medical Record
Patients Name: Pearle Mae Wilkingson
Patients Hospital Number: 00293845
Patients Date of Admission: 1/8/2012

History of Present Illness
The patient is 51 year old African American/Black female. The patient was transported from home by her daughter-n-law. According to patient daughter-n-law she has been complaining of pains in her right leg approximately one day. Family administered daily pain medications that did not help the condition of her persisting pain. After pain persisted daughter in law later brought the patient in to the emergency room for examination.

Past Medical History

Patient passed medical history was received from hospital records and daughter in law. Patient has history of congestive heart failure, serosis of the liver, kidney disease and hepatitis. The Patient has a history of poor blood circulation which led to her left legs being previously amputated. According to patient daughter in law two surgery where done for amputation. Patient first surgery was down to amputate below the knee. According to daughter-n-law the second surgery of her knee was done to amputate leg above the knee because poor circulation still persists after first amputation. According to daughter-n-law patient is set to dialyze three times per week for treatment of her kidney disease. The patient missed her dialyses treatment today.

Physical Examination

The patient is responsive while lying in the bed. During lower examination of her legs the patient right feet is noticed to be swollen. The patient right feet and legs is an abnormal color and feel really cold. Patient is able to react to feelings while leg is being examined.

Diagnostic/Lab Results
According to examination and lab results the patients. Peroneal artery was not circulating oxygenated blood because of blood clogs. The patient’s tibil is not circulating oxygenated blood because of blood clogs. The patient was dialyzed before leaving the hospital to avoid further health problems pertaining to patient kidney disease.

Impression/Discussion

Patient will be given the option to take thrombolytic medications to treated blood clogs. As method of avoiding possible amputation surgeries. Patient was given this option because of patient is in the state of being a high risk patient because of various health problems. After weeks of treatment on medication if body rejects treatment possible amputation of leg will be an option, which have been discussed among doctors, patient and family.

Two Questions for prospective hires

Where is a patient’s peroneal artery located and what is it primary functions. Where is a patients tibial artery located and what is it primary functions.

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