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3. What were the abnormal finding of the physical examination? 4. What changes were noted from the previous film?

3. What were the abnormal finding of the physical examination? 4. What changes were noted from the previous film?

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
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3. What were the abnormal finding of the physical examination? 4. What changes were noted from the previous film?
Transcribed Image Text:3. What were the abnormal finding of the physical examination? 4. What changes were noted from the previous film?
Respiratory System SOAP Note "Medical Terminology Systems" (2017). Gylys, Barbara and Wedding, Mary Ellen. FA Davis Date: February 1,20XX Patient: Flowers, Richard Chief Complaint: SOB Time registered: 1345 hours Physician: Samara Batichara, MD Emergency Department Record Medications: Vytorin 10/20 mg daily; Toprol-XL 50 mg daily; Azmacort 2 puffs three times a day; Proventil 2 puffs every 6 hours S: This 49 year old man with Hx of COPD is admitted because of exacerbation of SPB over the past few days. Patient was a heavy smoker and states that he quit smoking for a short time but now smokes 3-4 cigarettes day. He has a Hx of difficult breathing, hypertension, COPD, and peripheral vascular disease. The patient underwent triple bypass surgery in 19XX. O: T: 99.9 F. BP: 180/90. Pulse: 80 and regular. R: 20 and shallow. PE indicates scattered bilateral wheezes and rhonchi heard anteriorly and posteriorly. Compared with a portable chest film taken 22 months earlier, the current study most likely indicates interstitial vascular congestion. Some super imposed inflammatory change cannot be excluded. There may also be some pleural reactive change. A: 1. Acute exacerbation of chronic obstructive pulmonary disease. 2. Heart Failure 3. Hypertension 4. Peripheral vascular disease
Transcribed Image Text:Respiratory System SOAP Note "Medical Terminology Systems" (2017). Gylys, Barbara and Wedding, Mary Ellen. FA Davis Date: February 1,20XX Patient: Flowers, Richard Chief Complaint: SOB Time registered: 1345 hours Physician: Samara Batichara, MD Emergency Department Record Medications: Vytorin 10/20 mg daily; Toprol-XL 50 mg daily; Azmacort 2 puffs three times a day; Proventil 2 puffs every 6 hours S: This 49 year old man with Hx of COPD is admitted because of exacerbation of SPB over the past few days. Patient was a heavy smoker and states that he quit smoking for a short time but now smokes 3-4 cigarettes day. He has a Hx of difficult breathing, hypertension, COPD, and peripheral vascular disease. The patient underwent triple bypass surgery in 19XX. O: T: 99.9 F. BP: 180/90. Pulse: 80 and regular. R: 20 and shallow. PE indicates scattered bilateral wheezes and rhonchi heard anteriorly and posteriorly. Compared with a portable chest film taken 22 months earlier, the current study most likely indicates interstitial vascular congestion. Some super imposed inflammatory change cannot be excluded. There may also be some pleural reactive change. A: 1. Acute exacerbation of chronic obstructive pulmonary disease. 2. Heart Failure 3. Hypertension 4. Peripheral vascular disease
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