US Healthcare Systems Module 5 Case Scenario

Medical Chart

Name               Nick Morris                              Age      17               Gender   M   

Date    _______________   

Chief complaint

Patient is carried into the ER by several friends. They say he passed out during a party and they don’t know what’s wrong with him. They are not sure how long he has been unconscious. They were asked if he had been drinking, and they say that he has been drinking all night. One friend says he seemed confused at one point.

Medical history

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Habits (tobacco, alcohol)

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Family history

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Surgical history

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Medications

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Allergies

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Physical Exam

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Discussion Questions

1. How does a medical chart help diagnosis and treatment?

2. How might incomplete information on a medical chart cause a misdiagnosis of the problem or condition or delay treatment that could be life-saving? In Nick's case, his friends could provide information on what he had been doing prior to his visit to the Emergency Room. What if Nick's friends could not provide complete information? How would this affect his care?