Answered: C/C, vital signs, demographic, lab…

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

Section: Chapter Questions

Problem 1SRQ

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make an example of hospitalist consults for electronic health records from the scenario

Transcribed Image Text:C/C, vital signs, demographic, lab results, notes A 20 yr. old male came into the clinic,complaining of "pain when I pass my urine" Also complained of frequency and some urgency. Has noticed symptoms intermittent for the past couple of days but in the last 24 hrs. He has no fever, chills, nausea, vomiting, back pain, or change in colour of urine, and also underwent the standard protocol to identify what is wrong with him. After conducting all the assessments and tests, his lab results came back indicating that he has UTI which he mentioned he had before in the past and this "feels like the same thing". UTI treated without sequelae about 1 year ago Habits: Eat a lot of cup noodles and pancit canton when he is lazy to cook or in a hurry. Allergies: no allergies Patient Profile: In college, Nursing Student. Lives in a dorm with 3 roommates. O. Pleasant male, very communicative, able to get on/off exam tables. BP 118/78 P 82 T 98.8 BMI 25 Abd. Bowel sounds all quads, no tenderness to light or deep palpation except supra pubic tenderness to light palpation. No CVA tenderness External genital exam nl. No lesions BUS nl. Pt. prefers defer pelvic Dipstick: Positive for leukocyte- esterase and nitrates

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