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Explanation & Answer

Thank you so much Exam 3 and 4 are uploaded below

Running head: Exam 3

1

Exam 3:
Name:
Institution affiliation:
Date:

Running head: Exam 3

2

ER Neurology Note for Annabelle Ocegueda
This is Dr Burton R. Buford M.D. dictating emergency department note on Annabell last
name ocegeuda number 251978.Current date.
History of present illness. This is a 54 year old female who complains of dizziness
weakness for the last several hours as well as decreasing ambulation and unsteadiness back pain.
Update patient denies any pain or numbness and drowsiness. Denies chest pain, fever or
headache. Patients does report some blurriness in her vision on turning head from side to side.
Mild slowing in her speech noted. She was seen by her family physician today which identified
the ataxia this morning and has scheduled the patient for an MRI today. Patient’s symptoms have
since worsened and the patient has presented to ER for proper treatment. Past medical history
month 1) hyperlipidemia 2) hypertension 3) obesity 4) history of mild TBI blunt disease
traumatic brain injury and pregnancies after a car accident five years ago. Sexual history: The
patient lives at home with her husband and two teenage sons. Patient is employed as an
accountant for a local tax firm. Patient denies current tobacco use and reports quitting smoking
15 years ago. Patients had been a one pack per day smoker. Medications: Lipitor 20 milligrams
daily, decapitate 10 milligrams daily. Allergies: amoxicillin. Physical examination: vital signs
temperature ninety eight point two posts is 88 and regular restorations 18. Blood pressure is 140
/76. General: the patients alert co-operative at the examination. Age EENT. Normal sebalec,
head dramatic tympanic membranes normal bilaterally extra ocular muscles intact. Pupil’s perla,
oral pharynx is normal. Neck supple. No adenopathy. Heart regular Rate rhythm without any
murmurs rails or rumps. Lungs breathe sounds or clear bilaterally. Abdomen soft not distended.
Extremities: patient has upper extremity and grass plus and plus three lower extremities strength.
No logical. Cranial nerves 2 through 12th intact. Laboratory diagnostic: labs were obtained basic
medical metabolic profile showed sodium of 140 Tasleem three point eight chloride 110
bicarbonate of 21 glucose 189 logorrhea and nitrogen 20 and accritem 0.8.calcium is eight, PT
and partial time were 13 and 28. White blood cell count is 10. H and H is fifteen point two and
44. No Hemorrhage noted upon C.T. scan. Emergency room course discussed with primary care
physician who agreed with the admission of this patient. Diagnosis probable thrombotic CBA.
Plan: patients to be admitted to the floor for further evaluation management of probable from
Thrombotic CBA.
End of dictation. Thank you.

Running head: Exam 3

3

Gastroenterology Progress Notes
Note on Bernard luck records received from Dr. Huber. Endoscopy done by Dr. tu in
November disclose hemorrhagic gastritis in the upper two thirds of the stomach. The remainder
of the exam was normal. The ph was 8. In October he had a large approximately 8 by 10
centimeter abdominal aorta aneurysm repaired without difficulty. No time Samuel Paul received
a call from Mr. Paul's son this morning stating that he had had some intestinal bleeding over the
course of the weekend and that he was willing to be admitted for further evaluation at this time.
Subsequently I called City Presbyterian Hospital and made plans for him to be admitted today.
Shortly thereafter received another call from Mr. Paul's son stating that Mr. Paul changed his
mind. I contacted Mr. Paul and he stated that on Saturday he had vomited up approximately a
pint of blood. On Monday morning at 3 a.m. he woke up had a headache and thought that he
would probably need immediate blood replacement but now he's feeling better and no longer
decided to come to the hospital for evaluation. He just wanted to come in for blood transfusion.
He asked if he could come in today to have a CBC drawn as well as having his blood matched up
for them to return tomorrow to receive a blood transfusion. I suggested it would be most
appropriately handled in the hospital but he wanted this done on an outpatient basis as it had
been done this way several times in the past. Subsequently he will come in to have the CBC and
typing cross today and receive a blood transfusion in the morning.

Running head: Exam 3

4

Neurology Consultation for Christine Odum:
This is Dr. Michael Barton dictating and consultation on Christine Odum 261237
Date of consultation: Current date.
History of present illness. This is a 66 year old female who has indicated that she has
been falling because she is "tripping over her own feet." initially there was some question as to
whether the patient may be displaying some Parkinson type symptoms. Patient is a type 2
diabetic with mild peripheral neuropathy of the lower extremities. And concern was that the
patients pulse may be related to low blood sugar or a result of the neuropathy. The patient reports
that her blood sugars have been stable and when checked after fall, they are not low. In fact at
times they have been as high as 225. Patients reports that when she falls she is not able to get
back up and must wait for help to arrive. Patient Denize dizzy spells patients son is present for
the consultation and verbalized concerned about mom's speech. Son feels that mom's speech is
sometimes mumbled and slightly slurred. Son feels this change in speech has evolved over the
last year. Patient reports sometim...


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