Question

Medical Chart Name Nick Morris 12 Gender M Date Chief complaint Patient is carried into the ER by several friends. They say he passed out during a party and they don't know what's wrong with him. They are not sure how long he has been unconscious. They were asked if he had been drinking, and they say that he has been drinking all night. One friend says he seemed confused at one point. Medical history Replace this with your text. Habits (tobacco, alcohol) Replace this with your text. Family history Replace this with your text. Surgical history Replace this with your text.

Answer 1

• Medical history
  • Not known or available
• Habits
  • History of alcohol,duration not known,drank whole the last night
• Family history
  • Not available
• Surgical history
  • No surgical scars on the body
• Medication
  • Nil
• Allergies
  • Not known
• Physical examination
  • CNS:unconscious

1.A medical chart enables the healthcare professionals to correlate , compare, interpret, analyze and fang out the actual problem and gram a diagnosis for it first.Thus is followed by the appropriate treatment

2.Incomplete information is always dangerous. It can lead to a random diagnosis without confirmation and treating for the same.Certain history are highly important to known what type of medication or treatment is needed for a patient. A lack of allergic history and if patient is administered a drug in their routine can be harmful by making them allergic.If Nick's friends doesn't provide adequate information this may interrupt the plan of care by risking the quality of care on an unknown patient.In simple the patient can be hardly met with their right choice of medication and treatment with inadequate information.