HS 111 HS111 HS/111 Unit 6 Assignment Template

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HS 111 HS111 HS/111 Unit 6 Assignment Template

HS111 Unit 6 Assignment Template HS111-01 Unit 6 Assignment Sarah Knight Kaplan University

DIRECTIONS: Read through the medical report listed below and the follow the directions listed after the report

ABC Medical Center7777 North West Street, Michigan 12345 – (555) 123-4567

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PATIENT NAME: Deana MartensMEDICAL RECORD:8888888DATE OF BIRTH:3/26/1947

DATE OF ADMISSION:1/19/2015

PROGRESS NOTE

HISTORY: Deana Martens is a 67-year-old Caucasian female who was brought to the hospital via an ambulanceand subsequently admitted to the hospital on 1/19/2015 for dysphasia, dysphagia, and right hemiparesis. Ms. Martens has history of HTN, and High Cholesterol.

Husband states that patient is taking medication daily. No problems have been noted prior to 1 ½ hours ago when she began to show signs of right facial drooping and complained of cephalgia. Husband states the patient was unable to drink her coffee withoutthe liquid spilling down her face.

Per the husband, the patient was reaching in the cupboard for a dish, when her right arm started to fall. After sitting at the breakfast table, the patient began to rise, when she fell to the floor, and was unable to stand up without help. She showed a steady decline within minutes developing ataxia, dysphagia, and dysarthria.

OBJECTIVE FINDINGS: Physical examination shows the patient was alert, and oriented x 2. Mild confusion noted to place. Gait was not assessed at this time due to hemiparesis. Grips were unequal. Right pupil wassluggish to respond to light. Right lower extremity was flaccid.

Blood pressure was 180/92 mm Hg. Pulse, 78. Respirations, 18. Temperature 98.7. Chest radiograph, Urinalysis, CBC, PTT, Basic Chemistry Panel and ABGs were obtained. ABGs showed low 02saturation. CT scan showed negative for an intracerebral hemorrhage. A neurology consultation was obtained. Neurologist confirmed the diagnosis of an ischemic

HS 111 HS111 HS/111 Unit 6 Assignment Template

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