HS111_Unit6 assignment - HS111 Unit 6 Assignment Template...

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HS111 Unit 6 Assignment Template DIRECTIONS: Read through the medical report listed below and the follow the directions listed after the report. ABC Medical Center 7777 North West Street, Michigan 12345 (555) 123-4567 -------------------------------------------------------------------------------------------------------------------------------------------------- PATIENT NAME: Deana Martens MEDICAL RECORD: 8888888 DATE 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 ambulance and 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 without the 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 was sluggish to respond to light. Right lower extremity was flaccid. Blood pressure was 180/92 mm Hg. Pulse, 78.
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  • Spring '15
  • Iannelli
  • Deana Martens, ABC Medical Center, Rae Sibley

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