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 Patient is 65 years old African/Black male. The patient was brought in the emergency room department. The patients girlfriend said he has been complaining of unusual stomach pains. According to the patients girlfriend he was vomiting blood before she brought him to the emergency room.

Past Medical History According to the patients girlfriend he has a history of past drug abuse. According to past medical records the patient has a history of peptic ulcers disease.

Physical Examination The patient is complaining of stomach pain while sitting up in the bed. The patients appears to have a swollen stomach. The patient appears to have decolorized skin around his mid area of the body.

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

Impression/Discussion The patient was referred by a healthcare professional to undergo immediate surgery. This surgery is done to remove the cancerous tumors and also part of the stomach gastrectomy.

Two Questions for prospective hires What can cause a patient to develop cancerous tumors of the stomach? If a patient has ulcers should they continue to take aspirin medication products?

HCA/220r8

References

Chapter 4 Medical Record History of Present Illness The patient is a 46 year old Hispanic female. The patient arrived at the emergency room by the emergency ambulance. The patient is complaining with a high fever, dizziness, and a hard coughing.

Past Medical History According to the patients home health nurse the patient has a history of chronic obstructive pulmonary disease.

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

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

Impression/Discussion The patient is informed by the physician to get numerous amount of rest until the symptoms clear. The patient was given antibiotics for treatment for a common cold and upper respiratory infection.

HCA/220r8

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

Chapter 5 Medical Record History of Present Illness The patient is a 54 year old African American/Black female. The patient was transported from home by her daughter in-law. According to the patients daughter she has been complaining of pains in her right leg for approximately a day now. Family administrated daily pain medications that did not help the condition of her persisting pain. After the pain persists the daughter later brought the patient in to the emergency room for examination.

Past Medical History The patients past medical history was received from hospital records and her daughter. The patient has a 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 leg being previously amputated. According to the patients daughter two surgeries were done for amputation. The patients first surgery was sown to amputate below the knee and the second surgery was done to amputate above the knee. The second surgery was done above the knee because poor circulation was still persisted after the first amputation. According to her daughter the patient goes to dialyze three times every week for treatment of her kidney disease. The patient did not attend dialyses treatment today.

Physical Examination The patient is responsive while lying in the bed. During lower examination of her legs it was noticed that the patients right foot was swollen. The patients right foot and right leg is an abnormal color and are really cold. The patient is able to react to feelings in the legs during the examination.

HCA/220r8

Diagnostic/Lab Results According to examination and lab results the patients Peroneal artery was not circulating oxygenated blood because of blood clogs. The patients 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 the patients kidney disease.

Impression/Discussion The patient will be given the option to take thrombolytic medications to treated blood clogs, as method of avoiding possible amputation surgeries. The patient was given this option because the patient is in the state of being a high risk patient because of various health problems. After a couple of weeks of medication if the body rejects treatment then possible amputation of the leg will be an option. This has been discussed among the doctors, the patient, and the patients family.

Two Questions for prospective hires Where a patients peroneal artery located at and what is is its primary functions? Where the patients tibial artery located and what is is its primary functions?

References

HCA/220r8