Question

Medical Report Assignment #1

The assignment: you are a general medical doctor, and you must prepare a History & Physical and write some prescriptions based on the information below. The information is not in the correct order for the report, so you will need to put it in the correct order. You can use the History & Physical on page 42 in the textbook as a general guide, as well as the lectures, but your History & Physical must follow my instructions given here.

• The contents of the History of Present Illness must be written in narrative, using complete sentences. However, use abbreviations and acronyms wherever possible.
• For the rest of the History & Physical, write everything in the shortest way possible, using abbreviations and acronyms, and leaving out unnecessary words.
• Throughout the entire History & Physical, use the appropriate medical terms instead of the common descriptions given below.
• Do not use abbreviations that are on the JCAHO “Do Not Use” list.
• Do not add any information. Use only the information given.
• Use a fictitious patient name.
• For the Review of Systems and the Physical Examination portions, use whichever categories are necessary for the information given (e.g., Cardiopulmonary, Gastrointestinal, Musculoskeletal, etc.). If there is nothing to write under a particular category, you don’t need to include the category. For example, if there is no information given for Rectopelvic, do not include the category in the report.

You are welcome to work with other students, but each student must contribute equally and turn in their own handwritten work (no typewritten reports).

What to turn in (both handwritten):

- History & Physical

- Prescriptions (does not need to be on a separate sheet of paper)

Please scan (make sure it is easily readable) and upload your report to the assignment submission link on Blackboard no later than 11:59 p.m. on the due date listed in the Course Schedule. Late assignments will not be accepted.

Points possible: 50.

She is a nonsmoker.

The patient’s temperature is 37 degrees Celsius.

You determine that she has persistently high blood pressure.

Her pulse is 78 beats per minute (you do not detect a murmur), and her breathing rate is 14 breaths per minute.

The patient is 4 feet and 11 inches tall.

You will order a chest x-ray right away to rule out the possibility of abnormal dilation of the bronchi.

She says her last pap smear and mammogram were within normal limits.

You order a complete blood count to be performed immediately to rule out an abnormally reduced number of all cellular components in the blood.

The patient is a 74-yr old female who complains of right shoulder muscle pain.

You hear a grating sound coming from her ® shoulder, and you observe decreased range of motion.

Another possible diagnosis is degenerative joint disease and softening of the bone.

The patient indicates she has no chest pain or cough, but occasionally has difficulty catching her breath.

You notice that the patient’s voice sounds hoarse, and she has a runny nose.

She suffered a bending and incomplete break of her right thigh bone in 1945 (not an open wound).

In 1986 she was treated for diseased heart muscle caused by excessive alcohol consumption.

The patient takes a medication that reduces serum fat and cholesterol, and she is currently undergoing treatment for an abnormally decreased number of platelets in the blood.

You suspect the patient has increased sensitivity to pain.

The patient states she drinks more than 12 ounces of alcohol every day.

One possible diagnosis is that the patient has inflammation of the right shoulder bursa.

You notice inflammation of the nail folds of her toenails of both feet.

You see hives on the back of her left knee.

You instruct the patient to discontinue over-the-counter non-steroidal anti-inflammatory drugs.

The nurse took the patient’s blood pressure while she was sitting down, and it was 172/110.

Upon examination of her abdomen, you notice her spleen is enlarged.

She experiences occasional excessive sweating.

Her pupils are equal, round and reactive to light and accommodation.

She is not allergic to any medications.

The patient came to the office complaining of right shoulder muscle pain, which has been ongoing for 3 weeks.

The patient is an 98-pound female, who appears to be calm.

Her right shoulder appears to be partially dislocated.

She has a history of fainting.

The patient’s sister has high blood pressure, which developed slowly and has persisted for a long time, and she has excessive hair growth.

The patient’s mother is 63 has a mild affective disorder characterized by chronic depression. Otherwise she is alive and well.

You observe that she has an abnormal posterior curvature of the thoracic spine.

The patient states the pain began 3 weeks ago when she fell while running on flat ground. The patient said, “I was running away from the cops.”

The patient is a retired high school guidance counselor.

The patient’s father died at age 56 of a systemic disease caused by infection with microorganisms after having his thymus gland removed.

The patient’s brother died at age 42 due to a permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema.

You instruct the patient to return to the clinic in 1 week to review test results.

The next day, she noticed muscle stiffness, and was unable to move her arm away from her body or turn her palm upward.

She has taken over-the-counter non-steroidal anti-inflammatory drugs, two tablets twice day for 2 weeks for the shoulder pain.

You notice a solid mass greater than 1 cm in diameter on the surface of her skin on the front of her right arm below her elbow.

The patient says she has experienced some shrinking of muscle size, and says, “I’m not as strong as I used to be.”

You would like to order magnetic resonance imaging of the right shoulder.

----------------- End of History & Physical --------------------

Next, use the information below to write three prescriptions, using the proper format and notation required by the pharmacy. Again, abbreviate, shorten, and use medical terminology wherever possible.

Prescriptions:

For shoulder pain, you prescribe a 2-week supply of Tylenol with codeine 25-milligram tablets. This is an “as needed” medication. The patient should take 1 tablet three times a day with 8 ounces of water.

For depression, you prescribe an 8-week supply of Damitol, .5 gram suppositories, 1 each to be taken twice a day, through the rectum, 1 hour after meals, while awake.

For persistently high blood pressure, you prescribe a 30-day supply of Capoten .5 mg, 2 tablets to be taken by mouth at bedtime, every day for 5 days. Then increase to 1 tablet four times a day.

Answer 1

HISTORY COLLECTION

name :Mrs. Rose

age: 74 yr sex: F

personal history

non smoker alcoholic came to the clinic with the c/o right shoulder muscle pain.

h/o fracture right femer in 1945

h/o alcohol induced cardiomyopathy in 1986

she is under treatment on lipolytics/ lipid lowering agents, treatment for thrombocytopenia

no h/o any medicine allergy

h/o fainting

excessive hair growth, increased sensitivity to pain

she is a retd high school teacher

family history

family history of hypertension. father died at 56 due to infections and brother due to chronic COPD

PHYSICAL EXAMINATION

general condition

ht: 4ft11in wt 98 pound

calm, stable and oriented

vitals : Temp 37degree celsius , P 78/m with no S1S2, R 14/m BP: 172/110

system wise examination

integumentary system: B/L inflammation on nail folds of toe nails, occasional diaphorosis , hives on back of left knee

musculo skeletal system: frictional rub from right shoulder, decreased ROM, kyphosis, right shoulder dislocation

chest: no chest pain, sound hoarsness , dyspnoea

abdomen: on palpation -- splenomegaly

ordered for

chest X ray PA view, CBC

TREATMENT

TAB. TYLENOL+CODEINE 25MG TID & SOS with H2O X 2 WEEKS

2. SUPPOSITORY DAMITOL 500MG BID PR 1Hr after meal X 8 WEEKS

3. TAB CAPOTEN 1MG HS X 5 DAYS FOLLOWED BY 0.5MG QID X 25 DAYS