respirations 22‚ blood pressure 108/60. General: Physical exam reveals a well-developed‚ well-nourished 35-year-old white female in a moderate amount of distress at the time of the examination. HEENT are unremarkable except for poor dentition. Neck is soft and supple. Chest: Lungs are clear in all fields. Heart:
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EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seegerman Patient ID:903321 Date of Admission 3/27/2012 Emergency Room Physician: Alex McClure‚ MD Admitting Diagnosis: Eptopic Pregnancy CHIEF COMPLAINT: The patient presents to the emergency room this morning complaining of lower abdominal pain. HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding‚ more like spotting‚ over the past month. She denies the chance of pregnancy‚ although
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well-nourished 35 year old white female in a moderate amount of distress at the time of the examination. VITAL SIGNS: Show temperature 97 degrees; pulse 53; respirations 22; blood pressure 108/60. HEENT: Unremarkable except for poor dentation. Neck: Soft and supple. CHEST: Lungs are clear in all ???. HEART: Regular rate and rhythm. ABDOMEN: Soft but positive tenderness of her lower abdominal
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HISTORY AND PHYSICAL EXAMIATION OR EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 Room No.: Date of Admission/ Date of Arrival: 3/27 Admitting/ Attending Physician: Alex McClure‚ MD Admitting Diagnosis: Ectopic Pregnancy Chief Complaint: Lower Abdominal Pain HISTORY OF PRESENT ILLNESS: The patient states that she has been having some vaginal bleeding‚ more like spotting over the past month. She denies the chance of pregnancy although she states
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PATHOLOGY REPORT Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission and Surgery: 03/27/2014 Admitting Diagnosis: Ectopic pregnancy Surgeon: Rosemary Bumbak‚ MD‚ Obstetrics and Gynecology PATHOLOGY FINDINGS: Specimen number 03-S-965 SPECIMEN RECIEVE: 03/27/2014 SPECIMAN REPORTED: 03/30/2014 SURGICAL PROCEDURE: Left partial salpingectomy CLINICAL HISTORY: Patient has an ectopic pregnancy‚ as proven by pelvic ultrasound. TISSUE RECEIVED:
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upon arising in the am. She admits being “little stressed to family situations” and rotating shifts (DAYS/NIGHTS). Suggested to seek EAP (Employee Assistance Program) at work Head and Neck (pain‚ headaches‚ head/neck injury‚ neck pain‚ lumps/swelling‚ surgeries on head/neck‚ medications: LH has full ROM to neck and head‚ closes her eyes and able to hold her arms and hands out without swaying. LH takes Motrin 800mg for headaches. Motrin (ibuprofen) is a no steroidal anti-inflammatory drug (NSAID)
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will come back in the morning hours to see affected person once again. Patient Two – Chapter 7 Soap Notes Date: Mon‚ Aug 22‚2011 Chart #: 123-456-789 Age: 26 Name: Mike Jones Date of Birth: 02/02/1984 Sex: M S: HEENT: Normal Neck: Supple‚ not any swelling Breathing: No problem Extremities: Not any swelling Stomach : Not any problem Blood sugar :200mg/dl Affected person says he noticed abscess on his buttock and is having ache. He had been observed in the ER and a cut was
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. Health Composite Winston Salem State University Abstract The author of this paper has performed a health assessment on an adult patient and will discuss the findings in this paper. The author will introduce the client‚ complete the health history‚ and physical exam. While summarizing the findings‚ the nursing diagnosis and the plan of care‚ will be discussed in order to help the patient achieve health goals. Keywords: health history‚ nursing diagnosis‚ health assessment
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I. Introduction Dengue is one of the major problem of the Philippines‚ According to the World Health Organization (WHO) Dengue is found in tropical and sub-tropical regions around the world‚ predominantly in urban and semi-urban areas. Furthermore‚ The Philippines ranks among the top 10 countries with the most recorded dengue cases. Dengue is an acute infectious disease and severe‚ flu like illness that affects infants‚ young children and adults but seldom to death‚ virus are transmitted to humans
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HISTORY AND PHYSICAL - CASE 2 Patient: Benjamin Engelhart Patient ID: 112592 DOB: 10/5/1966 Age: 46 Sex: Male Date of Admission: 11/14/2012 Emergency Room Physician: Alex McClure‚ M.D. Admitting Diagnosis: Acute Appendicitis HISTORY OF PRESENT ILLNESS: This 46-year-old gentleman with past medical history significant only for degenerative disease of the bilateral hips‚ secondary to arthritis‚ presents to the emergency room after having had three days of abdominal pain
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