Example of Medical Report
Student Name
HCA/220
April, 28 2013
Medical Report Assignment
PAITENT NAME: Smith, John
HOSPITAL NUMBER: 859-656-6561
DATE OF ADMISSION: July, 23 20xx
|Chapter 3 – Medical Record |
|History of Present Illness |
|The patient arrived, complaining of chronic abdominal pain, vomiting, and feeling exhausted. |
| |
| |
|Past Medical History |
|The patient had been having some upper abdominal pain for sometime, and then, it escalated to vomiting along with a fever. Records |
|indicate that he had gallstones removed approximately two years ago. |
|Physical Examination |
|The patient is stooped over and has dry heaving from nausea. He looks sick, sweaty, has a fast pulse (120 beats a minute), and |
|shallow, rapid breathing. |
| |
|Diagnostic/Lab Results |
|A blood test was given to the patient. We found an increase of amylase
HCA/220
April, 28 2013
Medical Report Assignment
PAITENT NAME: Smith, John
HOSPITAL NUMBER: 859-656-6561
DATE OF ADMISSION: July, 23 20xx
|Chapter 3 – Medical Record |
|History of Present Illness |
|The patient arrived, complaining of chronic abdominal pain, vomiting, and feeling exhausted. |
| |
| |
|Past Medical History |
|The patient had been having some upper abdominal pain for sometime, and then, it escalated to vomiting along with a fever. Records |
|indicate that he had gallstones removed approximately two years ago. |
|Physical Examination |
|The patient is stooped over and has dry heaving from nausea. He looks sick, sweaty, has a fast pulse (120 beats a minute), and |
|shallow, rapid breathing. |
| |
|Diagnostic/Lab Results |
|A blood test was given to the patient. We found an increase of amylase
References: | |Electrocardiogram, (2013), Retrived April 27, 2013 from | |http://www.nlm.nih.gov/medlineplus/ency/article/003868.htm | | | |Medical Language (Second Edition, pages 142-144, 196, & 261-263) by Susan Turley. Published | |by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. | | |