Part 2 Female Patient Patient ID: Miss. F Date of Birth: 06/10/1993 Gender: Female Race: Hispanic Occupation: Works in a Factory in Yukon Marital status : Divorced Source: The patient gives her own history and appears to be a reliable source. Chief Complaint: “I am having abdominal pain” History of Present Illness Miss F is 23 year old Hispanic female who presents today complaining of sharp‚ epigastric abdominal pain of 3-4 months duration. The pain has not changed or worsened acutely;
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female in no acute distress seated comfortably in the exam room. She is alert and oriented. Very pleasant. She does become a little tearful when discussing the accident. Neck Supple. No posterior midline tenderness over the spinous processes. She has full active range of motion and does not feel tenderness across the neck with movement. No thyroid masses were noted on exam today. Musculoskeletal She does have tenderness across her anterior chest wall. She does have some bruising over the right
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HISTORY AND PHYSICAL EXAMINATION REPORT (H&P) PATIENT NAME: Emma Parker HOSPITAL NUMBER: 11259 ROOM NUMBER: 444 DATE OF ADMISSION: 25/9/2013 ADMITTING PHYSICIAN: Sherman Loyd‚ MD ADMITTING DIAGNOSIS: Acute intertrochanteric fracture of right hip She was alert oriented x3 with reasonable thought content. She understood questions well and was in no acute distress. CHIEF COMPLAINT: Right hip injury HISTORY OF PRESENT ILLNESS I was called to see this 69-year-old black female
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Case 02 H&P Examination Patient: Emma Parker PCP: Sherman Loyd‚ MD Hospital: 11259 Room: 444 Date of admission: 09/25/2015 ADMITTING DIAGNOSIS Acute intertrochanteric fracture of right hip. The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert & oriented x 3 with reasonable thought content. She understood questions well and was in no acute distress. CHIEF COMPLAINT Right hip injury. HISTORY
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HILLCREST MEDICAL CENTER HISTORY AND PHYSICAL EXAMINATION Patient Name: Emma Parker Hospital No.: 11259 Room No.: 444 Date of Admission: 09/25/2010 Admitting Physician: Sherman Loyd‚ M.D. Admitting Diagnosis: Acute intertrochanteric fracture of right hip. The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert oriented x3 with reasonable thought content she understood questions
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[He or she] is (alone or accompanied by). He is alert and oriented x 3. HEENT: EOMI‚ PERRLA. The oropharynx is clear. There are no lesions seen. NECK: The neck is supple. There is no evidence of thyromegaly. Lymphatics: There is no palpable cervical or supraclavicular lymphadenopathy noted. Lungs: Clear to auscultation bilaterally. There are no wheezes‚ rhonchi‚ or rales. Cardiovascular: Regular rate
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oxymetry 97% on room air. GENERAL: Normocephalic atraumatic. Fontanelle is flat. HEENT: Pupils are equal round reactive to light. Scleras are clear. Oropharynx is unremarkable. No lesions or exudates. Tympanic membranes were clear bilaterally. NECK: Supple. CHEST:Lungs were clear to auscultation bilaterally. No wheeze. HEART:Heart rate is regular rate and rhythm. Normal S1‚S2. ABDOMEN:No apparent splenomegaly. EXTREMITIES: Neurovascularly intact without rash‚ edema or tender joints. Normal tone
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bitten while she was at work 2 days ago. Patient reports that a client bit her on the right upper arm while they were trying to sit him up in a chair for dinner. The patient reports that the skin was broken. She denies any fever‚ nausea‚ vomiting‚ neck pain‚ back pain‚ or abdominal pain. Vital signs: Temperature 36.5‚ pulse 90‚ respirations 18‚ blood pressure 113/64. She is alert and oriented. No acute distress. Patient reports that she has completed the hepatitis B vaccination series. On physical
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HISTORY AND PHYSICAL EXAMINATION (H&P) Patient Name: Deanna Martinez ID No.: 117232 Room No.: 425 Date of Admission: 05/26/---- Admitting Physician: Sheila Goodman‚ MD Neurosurgery Admitting Diagnosis: Questionable herniated disk Chief Complaint: low back pain‚ right leg pain. HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago
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CC Bright red blood per rectum. Sinus pressure‚ sore throat. S The patient is a 62-year-old female who tells me that about a week ago she noticed bright red blood per rectum. She states she had a fairly normal stool‚ which was brown in color followed by drops of bright red blood into the toilet. She is quite certain this came from her rectum and not her vagina. She states the next day there was even a little bit more blood‚ and the third day continued. She then had several days where she did
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