Medical Record 4. 3 page 104 1. How old is Mr. Mars’? 51 2. Where was the treatment rendered? Does not say 3. List the three elements of the patient’s complaint Dizziness for 3 weeks, Headaches for 5-6 weeks, and numbness in left leg and hand 4. In your own words, not using medical terminology, briefly summarize Mr. Mars”s history: 51 year old male who has severe health problems 5. Which of the following is not mentioned at all in this history? (Circle your answer choice. ) a. the prescription medication Mr. Marsi takes .
Mr. Mars”s smoking habit c. Mr. Mars”s activity level at work d. Mr. Mars”s consumption of alcohol 6. Dr. Spaulding and Mr. Marsi talked at length about Mr. Mars”s symptoms and how theyVe changed recently, and then Dr. Spaulding examined him. List three objective findings she noted in this examination. (Any three of the following are acceptable. ) BPI 50/100, 7. Dr. Spaulding’s assessment is that he has But she T 98. 7 and P 76 Hypertension also wants to make sure Mr. Marsi does not have Congestive heart failure 8. Dr.
Spaulding’s treatment plan involves four areas. List the specific plan(s) for each of these. Diagnostic tests ordered: Chest x -ray, Electrocardiogram Instruct patient to change (and how) three personal habits: Decrease smoking, Decrease fat and cholesterol in diet Increase exercise to 3 times a week tor 2 mins Drug prescribed (and how much and when): Procardia XL 30 mg my mouth daily Future diagnostic check and/or action to take: Recheck Blood pressure 9. When is Dr. Spaulding expecting to see Mr. Marsi again? In a week