Answer Key Patients Medical Records & Charts

Page 1: Patient Information - Jane Smith

• Patient's Name: Jane Smith

• Date of Birth: 3/18/1954

• Sex: Female

• Height: 5'6"

• Weight: 200 lbs

Reason for Visit

• Experienced a dizzy spell and fainted

• Complained of blurry vision

Current Medications

• None listed

Personal Medical History

• Congenital Heart Disease: No

• Myocardial Infarction: No

• Hypertension: Yes

• Diabetes: No

• High cholesterol: No

• Stroke: No

• Coagulation Disorder: No

• Depression/Suicide Attempt: No

• Alcoholism: No

• Blood Transfusion: No

• Abnormal Pap Smear: No

• Cancer: Yes

• Thyroid Problem: Yes

Family History

• Alcoholism: No

• Heart Attack: Yes (coronary artery disease)

• Hypertension: Yes

• Stroke: Yes

• Diabetes, Type II: Yes

• Thyroid Disorders: Yes

Social History

• Tobacco Use: Never

• Alcohol Use: Yes (1 drink/week)

• Exercise: No

Page 2: Patient Statement - Jane Smith

• Experienced a dizzy spell and fainting

• Complains of blurry vision

• Reports unexplained weight gain, excessive thirst, fatigue, and headaches

• Also mentions trouble breathing

Page 3: Flu Test Results - Jane Smith

• Diagnosis: Type 2 Diabetes

• Symptoms: Unexplained weight gain, fatigue, excessive thirst/urination

• Blood sugar levels: 4.4 with a reading of 7,004 (need clarification on units)

• Management strategies: Regular monitoring of blood sugar, prescribed medications, balanced diet, remaining active

• Note: Diabetes cannot be cured, but is manageable

Page 4: Patient Information - Cindy Jones

• Patient's Name: Cindy Jones

• Date of Birth: 12/8/1999

• Sex: Female

• Height: 5'2"

• Weight: 120 lbs

Reason for Visit

• Complains of nausea

Current Medications

• None listed

Personal Medical History

• Congenital Heart Disease: No

• Myocardial Infarction: No

• Hypertension: No

• Diabetes: No

• High cholesterol: No

• Stroke: No

• Coagulation Disorder: No

• Depression/Suicide Attempt: No

• Alcoholism: No

• Blood Transfusion: No

• Abnormal Pap Smear: No

• Cancer: Yes

• Thyroid Problem: Yes

Family History

• Alcoholism: Yes

• Heart Attack: Yes

• Hypertension: Yes

• Diabetes Type II: Yes

Social History

• Tobacco Use: Never

• Alcohol Use: Yes (1 drink/week)

• Exercise: Yes

Page 5: Patient Statement - Cindy Jones

• Reports nausea and vomiting

• Incidents of weight gain noted

• Frequent restroom visits

• Trouble breathing and headaches reported

• Dizziness associated with headaches

Page 6: Flu Test Results - Cindy Jones

• Diagnosis: Pregnancy

• Symptoms: Unexplained weight gain, nausea, excessive urination

• HCG level: 11,300 (need clarification on units)

• Management Strategies: Prenatal checkups, balanced diet, active lifestyle, vitamin intake

• Note: Pregnancy is temporary and resolves after delivery

Page 7: Patient Information - John Thomas

• Patient's Name: John Thomas

• Date of Birth: 3/1/1989

• Sex: Male

• Height: 6'2"

• Weight: 140 lbs

Reason for Visit

• Complains of fever, chills, vomiting

Current Medications

• None listed

Personal Medical History

• Congenital Heart Disease: No

• Myocardial Infarction: No

• Hypertension: No

• Diabetes: No

• High cholesterol: No

• Stroke: No

• Coagulation Disorder: No

• Depression/Suicide Attempt: No

• Alcoholism: No

• Blood Transfusion: No

• Cancer: No

• Thyroid Problem: No

Family History

• Alcoholism: Yes

• Heart Attack: Yes (coronary artery disease)

• Hypertension: Yes

• Cancer: Yes

Social History

• Tobacco Use: Never

• Alcohol Use: Yes (1 drink/week)

• Exercise: Yes

Page 8: Patient Statement - John Thomas

• Reports feeling very tired and is experiencing vomiting

• Generalized body pain noted

Page 9: Flu Test Results - John Thomas

• Diagnosis: Influenza (Flu)

• Symptoms: Fever/chills, unexplained weight loss, nausea/vomiting

• Blood test result: 12,593 (need clarification on units)

• Management: Rest, fluids, and over-the-counter medicine

• Note: Flu is temporary but can be prevented by vaccination and hygiene practices

Page 10: Patient Information - Robert Smith

• Patient's Name: Robert Smith

• Date of Birth: 10/14/82

• Sex: Male

• Height: 5'8"

• Weight: 155 lbs

Reason for Visit

• Difficulty breathing noted, weakness after concerts

Current Medications

• None listed

Personal Medical History

• Congenital Heart Disease: No

• Myocardial Infarction: No

• Hypertension: No

• Diabetes: No

• High cholesterol: No

• Stroke: No

• Coagulation Disorder: No

• Depression/Suicide Attempt: No

• Alcoholism: No

• Blood Transfusion: No

• Cancer: No

• Thyroid Problem: No

Family History

• Alcoholism: Yes

• Heart Attack: Yes

• Hypertension: Yes

• Diabetes Type II: Yes

Social History

• Tobacco Use: Quit (2 months ago)

• Alcohol Use: Yes (5 drinks/week)

• Exercise: No

Page 11: Patient Statement - Robert Smith

• Reports difficulty breathing

• Weakness attributed to being a musician after concerts

• Describes muscle and stomach pain resembling soreness after exercise

Page 12: Flu Test Results - Robert Smith

• Diagnosis: Sickle Cell Anemia

• Symptoms: Fatigue, difficulty breathing, joint/muscle pain

• Blood test result: 9,001 (need clarification on units)

• Treatment: Medications, blood transfusions, pain management, infection prevention

• Note: Sickle Cell Anemia is chronic and manageable, but not curable.