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    2 2

    Uploaded by

    dr.kir97

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    © All Rights Reserved
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    MOCK PATIENT RECORD 3 PATEINT DETAILS NAME: 5:40 Zafieh bd Mekmet AGE: 29 years otch SEX: Ferrata, OCCUPATION : Santa HOSPITAL NO, : cocoru 841 DATE OF ADMISSION : 24/6 (202 8 DATE OF DISCHARGE oR Patent Complaint: 29 years aid, nAatny fenale, GPO aH 3E weeks ace aE menarrian antly Symabcal intemescing green oeeinn CLUE) tHE EEE canta Gn tale: CAPD Sel, Neal eMC GRRE Gap iar and co ete SE Tn weet ATE eas Boating, Sas” San | TO mecha. CT NC TES Cea, BME LAE HE Tamang, Bs VAP RG PAnanndal tee CANE) SENS Lat Candice, abnermatites Canentapedh AvSD AGA (eter Wiredlan Nt farcjomatan Aine owta bioheg F ened aeunee) Ee lees gies) Rett 2 Coren) = exe -oe : anak POR «Gee caieeh cD NStha oN Rents care wee Ueto ds keggeenee TMGR [Great eettretien Previous History oS Meaadtert ; he Known manttenl these eae ~Syemreny, oops semesters IT hey eT eae Kempttemtion frm the surgery, Weather Soratns 7 . H Oboe ths we bar ess pegnemey fteaned pmaneny Ne C CoCe Antes triers nie pap tener dere Eaters Se eg Ora | Digane gucted tem 18 doge Cheeats ped Cun8 Httd eee OUTS peta Sagas pore pt oe we Other anne ne Lee (A 12022 eyele | 28-80 Any auntie ne post mererbags re dggmenertan, ne Ausper ital Klewding PF no intrminstnal bleeding, sccaifaaty Wass) en pecs = walt eee een con ieee eer eee ea CO ce Sk oo beter fies to a Dison lca tet Se oS po PHYSICAL EXAMINATION Blood pressure ter (go. mmHg Pulse rate 30 fin Respiratory rate \& min Body temperature 366 poz too % & General examination Canscious nltct ond erential. Lying Comfortable 99 Supine poston SL Ts not pela 2 net echypreve She TS neh IR PAIR Hydretionns| ond nitiona\ setus TH adequote A Hand! Beanula stincked te ctght dorsum of her bend Pate, WOE Leneen, pink and day. Ne exer Fad dorsum due te branula insertion. Cag Many weft ea Te <2 Skeends Pulge rate Stee Fa tery Tae RON kenderrnce WH, Feguiae chythes jrormat volume ino. spectant draracter re adic —omatral datay (ne radia’ -Feeneral datag and re Cbopsing ratte lowe Neb No pedal edema or no cath tenater ness * Audomen Ree Rete, Sanne te Gare he nea. oe oF Deke ning mm urctltem| 13 tintenky lecmtest, amok geeried Abdonan Te S0ft ark ren tender, Cinreatty eee ges eas eect a Oe ee set Wo dete A Eingeten fetus SEL longauctinn | ee ee Bee te gd mateenn ls PA Baby Bead OS other parts Cyable 816 tate OTT on Menmulatation, tal fart counel cco TL Rate eateries Bhavan atprenimat yy gate Wiad NG thers, Venhiticus. the ve Loquecr Se midequate -Eetnaded fetal oeighs betow acus 1 buat hytha -no mUrmer : mie antry ne ert pitectvon sw tonge “Eavet s sof qevtatren SHO PROVISIONAL DIAGNOSIS :24 wlo (GIP, 36 weeks of gestae Mtenadacine proudly eesieicHen UUGR) INVESTIGATION: LRT —PCR E Negative 2A blosd cant THE Ey glal Creel) sPlasetat 1184 x (OTL Caterenat) srvevdrophiles HBG HOT L Coigh> cLymeboeyiee 1 RAF LOL Cigh) eWee ISA KLOTL Chad) SB. Cte, Rametref1G ,ne contraction 4 Granth chard ‘Mead elreumferance anal abdomine\ Cirtamferenee << SA conte. 5. Wrenscbdominal scan Tsim seen + Placer: Geptr segrect rc sari ver hey keg Vetemetey 2203) wants 0 Se eee, en) pase ne rserer THACAl Tteapehen HRtorennt GS 2/7) PBingleten ® cep hei i Fetal beard seen Ghoun te motte) MANAGEMENT PLAN Loker TA Denametharre Dwg 89 1/9 2.6XG 08 wa meget HopAIRT IATL on Hhuadag ® Fridlny a planet Bihan cemetenge ee A mab Be encore Bote ITT e gaqtantnes section on slei2ets C ee geen wnfth BND minimtninenes CG beort pier? a.keep Eat tem RR he Ge eh) ae For annaeh. Su! &@ © fore branute te OF op CAV Mereten Omg on, NG Sedienn CHE OAM 3Oce lerge ac ere ae proete uO “A oN? “a aFonetor WN pertey Ot cae ne oe gv dratyn UBS ot & blow ence PA abort do deliver 7 J local - (2. tafe? Cee PROGRESS NOTES / DAILY MANAGEMENT DATE/TIME: 26/8]2023 CG ¢~ corset, Beg hak nomen Coe = Coe IRS comraction TNe Goking Wequer Jae neces OE. Alerd not pate BP 1100 /Ca mag (PRU AE wine ARLENE Y o> gomtates TR RE renter sem Fe HED MERE ARS BE HE PTE BET = GSH AY Gntteody oN ~ MagssssrglerenseepheNesnrs ath doppler ‘re-ce=! een As pened atectve Efecto On = Conant done Pee wrest Cordered) ~ tock OF ~eanp NEM at om STUD meintainee ~eXG 8D sols poze, Bees four eee A eee ea: [REFLECTION AND DISCUSSION OW LEARNING ISUES fee Seep ack OB ry mca Ree Ment tek Was citedle j katte use [akouse, pro teleergsion, Chess prion TUGR, untermrition , % eemahiten pameking alcohol een Faget sacs TM Saget 8 CL We a _ Batemans TTT ewes i tecentah eco Were Siireientg reduced oe atitn detiveng redee oeice shag Se ote acing DATEPREPARED: 247 clooss Kictonsaheee Areas Suse Name of medical student Signature MOCK PATIENT RECORD 4 PATEINT DETAILS NAME :Nenang Indien AGE:43 gears ol, SEX: Female, OCCUPATION :Hess* heen HOSPITAL NO. : 0900926206 DATE OF ADMISSION : 35 J5|2023 DATE OF DISCHARGE TETORY Pas coapied Tee, Ee ee tale, Pern 2 holmes eT Regee acrqena er deta ablowinal hytteacteny oY Siciaes Craugse) 29 2 eS pues i , Ae A oe gery nce ec NS ee cine -Meewy Anses Since Lad year Tun kG days -partoudly tquieing 4 pads ve deed SN igen wane akauece ter ta ne ec anion, wale s pain, ne hewel oc Urinary Ay bilateral Sal pings -opphorectomy Tnemensing August jlasas also Orhensise no abdominal eo Watgha Te mppette or Ge 3 tens jae lose oe ; Prsyiets HBO ie Sxacn atten, Yoo? seat cf. utec anos. tredtca\ cattery ah TE unser OF the mech! Gabon Mag Crerning) ara che cleiwed taken ence dats % nee AN Ae check up at felvede secctoy— by the family she wots for ( my (precedire oar dome Veen breed aay een tn el by L Ne known SuTat conpicertons, AB meets, 2A KR SVB NO cone" Bk caeebs 2 Leg SNE PTE Come licetons “ eld, pretousty had regulon Te poke Fully soeted fia 2 oo ae ~ Menten ap eat dmye of eyelet ruse eons ere SociaVFamily History: Neon senater jre Welt drugs taken, re alcohol : stony TE. unrérnerkatte > Stays © uit Contumpion . Family Weston * er working foenity COutrminan) {SA works ms a heat clanqer Ber tent te AU Ge deere as © Digagy ne Kneon alergs Ange ond e TE pe tiewe Bg (rene nee RO SE Hedthrenet medication cn PHYSICAL EXAMINATION Blood pressure; v3) 61 mmilg Pulse rate 4 /min Respiratory rate 3 min Body temperature 36.26 P02 1 Ae % * Gantenl examination Conscious jalert And Onented, Lying, comfertoble in supine gente, She Ty slightly pale ard net tachypne te + She Je neh an pain ter mytretonel & nuttonel status fs adequate wetland Bramlea attoukud te aght davsunn yet hac harsh. Patan ware waren fink end dings sanm, bat) Vendarness Tren Mek gh Woctien dua fe econ eee cD seconds Pulse rete were chgthen proreral volume .ne rodie- red! ciaering pus Copilary cenit Keone 8 BU bees with ceglen special charecter ie {delay ine redid Kenparc| delay and re Lower Vink ; iene = xARdowmey Aidomen diatended with snass. No prisence of Geto al 3s cantrolly lecedtdh and inverted mages Uaete e ae Tee sdealg (Urn He Aidoren ve S@htly herd bot wd BO ceks of site On pilpntton mace TS smooth suchen fern in consistency sete fo get tatow Gn auscultation pleowet ) Currently, Comfortobte tole ralve ebdowinc| locksn roeal Axcomfert , pie check pain [pmipitedtons [Som (giddiness /cedvced effort Jolerance Complete Bp packed cel! Completed | Pu at SSH NSS eetve complainas cycle BING Uthert Ole * not ete eek e Stokenaeineween S'S Poe ee Binet ods tahiange es eet el Sirinms tee coe Satie) oS kre alan Roehedat meat ee Pep retiles, ners Piom or haan fore weenie ~ Eee Tank for ertdenee of Infection (thrombosis. eee ge SE ng SAT CeO te AT cettcciad ESE “rea Late ee! ° ‘ 7 ore a MO an ee sataing Aha caine $e ee Lohans ore~ seere tl WE contracted at (Gus Fe frees Cane te comet tt sate REFLECTION AND DISCUSSION ON LEARNING ISSUES « Ve Causes of PPM Tpcneey t Tore CHAER AE Story ) a “rsernah (Onde: foveal 4dr) Awnitin CConquintion atttorder ONC 2 POH fabori camino ht) AUesue (Retained placenta) Retained predvets of + « Skcondany denen tings Sr pee Cate ne tebe) Stradws ef dead Aeene “s labexe obected Grenkdown of wltrine word Cater €- secdten) DATE PREPARED ; >[%(2025 Kirdonathewe Aras Name of medical student MOCK PATIENT RECORD 6 eee PATEINT DETAILS NAME: 12eAul Aing ink Subeinn! AGE 230 years o'4 SEX :temele OCCUPATION : House wife HOSPITAL NO. : co00%3 6¢ DATE OF ADMISSION : 2> [5/222 DATE OF DISCHARGE HISTORY Patient Complaint BO wie, G3P2 Claet Kein dat Auecks B days ceed of geration presented GTth per vaginal Meeting since (el Bora Passed od Preduct of concepts K days cage She Cletved A eh Arash blooel. Sie osed 3-3 fads pAilly toated Wt pan scone of 2 (10. Fost Pu Utes he wterteh developing cramer abdominal pats for des jdrechen er He des CHS 7 te Soy Aasts apmeda (day enter) wombting 6 ohn Cees gupedah ne tom ee ee Oe nes) Oacsee cow oe 0 arr ae she derngee Were “da. feos! Re chai sat te pet Srars:jco Gn ef ont aa oa me hash pei SOR, pate te Previous History Hredicat (NS Enoun mandical illnesses, : SAO ioe ie re Eacguny Enero Caen > —Seratcnt [erscedure ens clerk lenfort Ee —* * A vie s+ 1 2B 2B eaehS ig ELS emuses fer tetech Bee aba? Eeeceyp eae era) corsets je gesee ee eicah casio Law as emensrval he At A eanerche at age of 13 Uh egar Tenses Caan stale «mac - no canes Not ie eee ea eee Social/Family History Won eels, no Wicid dings taker pro alcohol Ren Family history TE unremarkable Stags WW Potatoes har huckand and childetn of Stereo hevsewike. Drugsiallergy swe known allergy to dngs on tood cnek on medication /traditera) medierre Prestend ce aes PHYSICAL EXAMINATION Blood pressure tow /e mmblg Pulse rate toe fin Respiratory rate 0 /min Body temperature: 39 6 sPoz ae Gcmrat 6 DATE OF ADMISSION: 34) 5 (202.3 DATE OF DISCHARGE HS (eee. Patient Complaint BB gle GSPOAZ a4 AB wonky B days caftrrseh from Glonabin we cue at Paha Som trantelemgtio clue to nn es The hesitant Caneneral sue) Noted Llood gressvre Wekeg Nea in Columbin ASR 1SOJ100 with " oiee Sa ae Aeroty a eeu Stet eclorpsia, Met ay ony hurretensiva medication me cetions ee Show te te Eg VAPL neremal Peni ctteanrnl ah, Sse iz ee Tae greets chert ISG4 singleton ,cephatie s ee ene nd to winch at Coletta Ata SOT GR NS Toa Tne athena norneteneive: throughout STS ccran wing sen cE 1 BORO SORES CEE Bleak glecane watt contrat) a NS Tg clemetin ox vfelel movement good snatin labore eviows sory Se pe Oe eee Eee DECAL TE SR THES tnceneplete miscertegas back SB A Sen Been gke: : a aieng of 2 peettone niscarta8 ibenedoate eg = Soci teenage ctesanet mone ort AT ee ee adage oF wraenstoel SYED vEaaus, Changes cad (2-4 Bees Regus meee SEE Coe ado Aus | dass dey te NESSIE ES rene tepereorin ne Snare ne caret ee maay becting. font ere! CeAy WAcomple te, (2 gears SocialFamily History: Non—trraber no Werk dugs token no alesho\ Consumption Both her parents have hupertension and on mudiratton Ste werkt aS an accentent She cage er Aithand ab Beate fa eGala Lomeur Drugsiallergy !=n'o Known allergy te dings or fecst Ton te Metformin FOSS, OB Sabi en Arealiternd wecttemtion Loong Here SE ack PHYSICAL EXAMINATION Blood pressure 152 fico mmHg Pulse rate 5 4G fmin Respiratory rate 1 /min Body temperature Ae spor 100% General aneminetion Conscioos etert andorientd. Ling comfortabl® in lateral positive -Ske is not pale & slightly tachyonere “She Tf not in pala Wupientronnt ancl nudtone| stats 1S adequate Hand : Rromula attectesl te her (eff dorsum hand . Pedan were cade pink ard ary Nic Scar but tenderness over her lett dortum due to branula insertion. Cagtlamy rel Hee is <2 seconds. fulse rote he RE Ge eye te Le eee ee no Special character ne radio radial delay ino madiomferraral dolow arel r0 callmpring, pulse lower Geol t No pedal edema er so at tenderness *ALdomen Abdonen shstended orth grntd ulouc thee & prsence of Urea niegrm jcrnbitcal TS centrally located ancl evertech. Abdoren TS Saft and ron ~tencher . Clinical Rural height TS abet 33 em came as gestabonnl mq TE Te a Sirgleton HES GUL longitedtinn! te Balog's beck Ts ad medermal’s eth od beby's parts Gh eternal s a@ht Bey teed 36 BIS palpable. Liquor TS adequate . Fvtimerttd tal we Gin aokishedaton, tal ‘bear soba onic ahemnstuad Aha. anterion Sheidar apprenimeately below onbilecos , “he mate 1S (BO bem: beisk _dual chathen « speeties + Not ONS ekese ts Lerge clear / PROVISIONAL DIAGNOSIS ; &3'e,G3°O 52% wath pet celempsion ne crepitections waueas 5 das ight TS chowt 16-8 bg, INVESTIGATIONS = 1 RAK - PCR rmregedve 2. Full blood cound FEET gla Geer et) ELAS 30% ALO L Wuormat) | WEE | 6.01 F LOT LCNorme) e Neutrophils £ 2-21 tOL Crorenat 3. Renal profile + en vee prea ene 08 *Get ue 4 Une fonction 54 t AST. 3F FALTEU 5 Comguiation prafle = P= 10 ,aPT 34: TSN 8F Gg Teensatdomincl Scan | Singleton, cephatic Meormat Atl, eoimaded Bath, weight HUA ky senatl fem qestetreral age CSGAD. MANAGEMENT PLAN Worse nates en aervel a ae os \ ect emrargencn 2. Adwit to lokoor Gort w Gediewe AVL MgSOu maintainance (genfhe for reurepretention qeriemee prteactemeea pekle tnken S carte Adal LOng TOS BE compass Ten pean attnsone, os BO 4 rent at 23604 a Keze i mouth (RBM) at dam IY te post gate gett tech TF chreranl FE poRh| hype cen see casts, fo si as B Byretorns oF MQ SOy tonicity 2o-HOce lhe. a. wedchow! vane ovteet lo. Marnrein oa stoding Seale ext ao, PROGRESS NOTES / DAILY MANAGEMENT DATE/TIME: 30/8 2923 C3 an Comenity * Tnformed BY staff nose ph bad [eating Attended STAT te kever ,gocd fetal morvewent ine eQns BR eymeteme = Chavwamnonitte not pale Ofe * Alert, Consctoss ' PIAS Sqfl pon-dender D 32 weeks singleton ,cepha ie Lelete pepe BFS EU REQ jelintent adequate laatthy 02 cloced, pooling of Liquor cod Placenta , Tg seained VV RAG, Conn se peice Sones plan: Saad EES BeOrq STAT Hen BO aA Blagyl BOO~g STAT Hen tos ~ sey gad chawkeg- Inform, NH mecoriing Stemed leper or ony signa symptens oF chodocminiatts. Ty petted daveloe regen contraction de elact AV ampicillin - Im Caxawethasore 1 nen Xo compede 1 remy BD nent et 23008 REFLECTION AND DISCUSSION ON LEARNING ISSUES USevene pre-cclameria ceiterta Cpresence of (at thend teee e eGo co higds pVonehiy nia mate Ge tee, ncmiate ak Mea MON cets wets, ot oe ee ee SNe a eat es a ee te SOIR, A ets eee oe eee age TOTS ERAT ce prettiest toddacbe Se Se eee ease eee, Ef Se asccnes Ha Naas Sas een ce eetinn! hewertages fexdates (nagihedarme ;placentel alroption aiyperiensive entiS. Greore ee &P S¥ehereneg fore a ee ee DATE PREPARED : 3\]6|202 3. hemasheee Ares Name of medical student MOCK PATIENT RECORD 8 PATEINT DETATLS NAME:S38 Fein bt: Shanahan AGE: 24 yenrs ated SEX :Femnte OCCUPATION : Ciere HOSPITAL NO, soscou3a2s DATE OF ADMISSION :20| ¢ [2523 DATE OF DISCHARGE : HISTORY Patient Complaint: AT gle GuPAt! ah SH weeks 2 days period of amenorchen cont for bloed gugnr prefile revigw) OE Eng gerrta! eohere the encling sews 6.0 /5-8/6:3/6.0/5-91 7-41 88 EOD 3/9 \2023 dated ot 9 wel dering besking Scan. ANC Oued Avebetes welts ~ Hixtony of gestational sn geagnenyy Use cineaigaeeeiony 2 meres AGT gent parte Genny recat Shent te bake Pees mech 4 AML Le LOA Pregented to Apc\ ao28 C3.2%) On To mettscmin (0004 80 wOotatied team Pgretsty Nerval tec ee Fp creo Wg wg Cutten soa) Ont Acer Uh Oner masters ia labour gegen! meversnt Previous History Smasteal erie Kreum: caltesk Ansa + : corks ee ee Bercy | Gore aeernenng Goa aa fuoctoct peeqreme aN other procedure [surgery Was dane obs We: tte midcartage =m DAS sna dere 268 compte mening 88 OAS ET cug 2B on dex eanbal : He sinc eossaken Lue. te, drrcavers’. [leith , abou U-Skq Se ee aat eb temp eee, ena gen om Ee eat n00 i ta ae eres oieas os eee Ol, Rent erent TS Gace cha HS ee dette Fest oa se dng wie dyrerorhta plytpareuriad port tcl Lied sotifeny andy etc emae Sul ct ues Cee es Caen So Gees Cake oe a areten Ste Gens Sh Qe Se cr ee Tass oS lar Kittand A childneg in Puchong. fiecyy <2 dem Si food Drugsallergy: Nic Krew alleray : ime dradiivenal medication hageine“porpese, On Te Metformin (OSOmq BD, T-tinester (1 00 a eee PHYSICAL EXAMINATION Blood pressure tos /33mmbig. Pulse rate 38 iin Respiratory rate: (3 iin Body temperature 26-46 SPO2 WA % Gear! Cramineton Conscious jalert and orented Laing conmfurtabig on (eft lateral positon She fs not pale rot teehypreic ond Tn ein-Her hyleotone| ancl nutvenet shetus ty adequate + Hench ]_Brevle attnckedd to ber ght dersin hand. Palen fg vitem, PAE ond day nte kee but tenderness over a her ete dort af Red sdut to The Leamula insertion. Capivteny ABU Bane Ts <2 Seconda. PUKE rate were Ag Leotg fer minude with regular rhythe, rere voluw® pre special Charecter ro mibionrndin| ataley ne vedio -Femena \ delay anh ro collepsing pulse net Flower lime Ne patel edeme and no Colt tenderness. FAldomen 4 Abdortin is distended with amv’ utews tare re CREE SE TREN S a Sete re viteen ntitient Te centey (cated amd averted. Abdowtn fs soft BB RES eG shy fetal Meight, arent, Deer then dete 46 coy TE TS ot tndieton totus GAR cephalic presintetien ond Hudinel: tie Balyts tack 13 ot maternal! olloaatelg fork fe nt maternal ® right -Bebs bead is 8/544 pable Eetmted aby eight 1s 2kg.O4 Be aera ant ene tee cece, «inn dha entener shoulder ““PPeRimatety belay mbites. the rote Te tht bem CVS FNe murmur jduat chythen + Rept Equal air entry bilaterally mmo crepitedins ISIONAL DIAGNOSIS: 325! ,GYPL 4) 4 By weeks with dicbetes meltites and large for gestesinel eae INVESTIGATIONS : LRH. PER NegQatue 2. blood Count | PWR TT-3 tal (Wormaly PUT IAB R107 L Crorenet) Few AME LOT LL Crore) Fwee 6.0m tO L Norm) A ckenal protic + Uren 20-9 pice oS tee ota Maan FA ave Jag moe So Trensebdominel Sean VSingieton cophe tee x Tee tenet saan yahoo te Om eeN J bee 188m CAL ea OD Done s Baa twine Cae a0) Tne MAR Con of romgt) Det: ee mms ct a) LAEL 28 Cpetuhyenemion) D etqcante Foe MANAGEMENT PLAN li tence cereal patile tater Ts 4 Bey Beat ee gp Seret diabetic Aiet -not “fer culstle feod until deb very dino veter opthalmelegd ctedey fo lest for diabetes Fe emis site nine endocring ctoday for blood sue petit opti Sate GIG BD a cic fetal feb chert Eo qefor SUL € srgns B sumptome of labour ( Bolced foal” sodeanh “ee Seca ine elective loner Stqnent Co Seeton + bilntersl tubal afer et a Adlys for 2 previon Scowe with gett ee tC ieee tos Contye Te ietfernin ty 8D A © unit T8S ord SIC reistard Cone ons AS (Ane on —teke before brenktned iaitesbesy Mt PROGRESS NOTES / DAILY MANAGEMENT DATE/TIME: 31 [51202 Cu ewe) Currently, ' Ne contractions one luating po thew ,ne abdominal Pain, ne

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