Read the following excerpt from a health record: SUBJECTIVE Mr. Robert Luno presents to our clinic...
Read the following excerpt from a health record: ΗΡΙ Mrs. Roxana Collach presented to the ED with a 2-day history of increasing epigastric pain. She described the pain as constant and dull with radiation to her back. She also had progressive anorexia. She denied nausea, emesis, or diarrhea. She was febrile in the ED and had marked epigastric tenderness on exam with guarding. Her abdomen was slightly distended, and she was mildly jaundiced. Her elevated amylase and lipase confirmed the...
The following documentation is from the health record of a 42-year-old male patient. Physician Office Record Entries Hospital Copy: History and Physical Admitting Diagnosis: Herniation of intervertebral disc, L5–S1 right side Present Medical History: Patient is a 42-year-old Native American male who initially developed problems with his back in July of this year. He was treated with anti-inflammatory agents and started on an exercise program; his condition improved enough to return to work. About one month ago, he had recurrence...
The following documentation is from the health record of a 42-year-old male patient. Physician Office Record Entries Hospital Copy: History and Physical Admitting Diagnosis: Herniation of intervertebral disc, L5–S1 right side Present Medical History: Patient is a 42-year-old Native American male who initially developed problems with his back in July of this year. He was treated with anti-inflammatory agents and started on an exercise program; his condition improved enough to return to work. About one month ago, he had recurrence...