76 M E D I C A L T E R M I N O L O G Y : A P R O G R A M M E D L E A R N I N G A P P R O A C H T O T H E L A N G U A G E O F H E A L T H C A R E

Practice Exercises

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5 . > 1/ 4 } A

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• HISTORY AND P H Y S I C A L

Merrel l , El len

'Wm^Sm&miMmm Fatigue

June 1, 20xx

The patient is a 49-year-old female who iomgfSf|si iffjfeeling very tired for more than a month. She states that she falls asleep within 30 seconds of her head hitting the pil low at night.

P A S T M E D I C A L HISTORY"^ The patient has had the usu serious miuries w^accidents. Allergies: JiQEjan'osmftogiaWergj^-eBs^^ F^t^^rTnTTi^ppr Both par ents m their 80's, are tS0^IA3si'HISte)R3&! Occasional alcohol consumption. She is a nonsmoker. O C C O P A f l O N A L HlSTOR^y "ITie patient is a retail clothuig manager.

^ ItEVIEW O F S Y S T E M S : H E E N T : Occasional sinus headache. C A R D I O P U L M O N A R Y : ' Occasional palpitations. N o chest pain, cough or shortness of breath. G A S T R O I N T E S T I N A L :

Some increase in weight recently. G E N I T O U R I N A R Y : Recent pap smear and mammogram normal. M U S C U L O S K E L E T A L : Negative. N T i U R O M U S C U L A R : Negative.

-^PftYSICAL EXAMINAtroN;

GENER .-a. A P P E A R A N C E : A well-developed, obese female in no acute distress V I T A L SIGNS: Blood pressure 110 /70 , pulse 80. respirations 16, te'mperature 97 degrees F, height 62 inches, weight 2 0 6 pounds. H E E N T Pupils equal, round and reactive to light and' facjcomniodati'o|i.;. Tympanic membranes are normal. No sinus tenderness on percussion. Oropharynx: Clear. N E C K : Supple; no masses or tenderness. N o thyromegaly. L U N G S : Clear to percussion and auscultation. H E A R T : Rate: 80 and regular; normal sinus rhythm; no murmurs or gallops. R E C T O P E L V I C : Deferred to gynecologist. EXTREIVHTIES: N o clubbing, cyanosis, or edema. N E U R O L O G I C A L : Physiologic.

L A B O R A T O R Y D A T A : Chest x-ray, E C G , and pulmonary screen are unremarkable.

' I M P R E S S I O N : L FATIGUE 2 . H Y P O T H Y T I O I D I S M 3. O B E S I T Y

' p t g g l i E l l O l M i N ^ ^ Draw blood today for C B C and thyroid panel. The patient wi l l return to the office in one week for test results.

Reyna James, M . D .

RJ:bst D : 6 /1 /20XX T: 6 /2 /20XX

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78 a M E D I C A L T E R M I N O L O G Y : A P R O G R A M M E D L E A R N I N G A P P R O A C H T O T H E L A N G U A G E O F H E A L T H C A R E

PROGRESS NOTE

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23

Merrell, Ellen June 9, 20xx

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Thyroid panel is I Hctof23.

The patient returns for lab results. She still feels "J tigtle" but admits to very heavy and irregular menstrual periods for the-lJast 6 months or so.

21

The CBC reveals a Hgb of 8.0 and

1. Anemia, probably due to iron deficiency 2. Menorrhagia 3. .^^obesitj- related diabetes

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.'ij^ 1. Rx: Feosol 1 po tid with meals 2. Repeat CBC and include serum iron 3. Schedule glucose tolerance test 4. Refer to Dr. Chang for gynecological followup

Reyna James, M.D.

RJ:bst

D: 6/9/20XX.

T: 6/10/20XX

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