Lymphatic and Immune Systems

Fill in the following medical reporting using the words listed below:

• itchy
• runny
• allergies
• dander
• medications
• distress
• heart
• drainage
• Dyspnea
• rhinitis
• iron

PATIENT NAME: Sally WESSON
AGE: 43
SEX: Female
DOB: September 26
DATE OF ASSESSMENT: March 20
ATTENDING PHYSICIAN: Trevor Sharpe, MD

CHIEF COMPLAINT: Allergies.

HISTORY: A 43-year-old Asian female states being very tired and irritable. She had presented watery and __________[Blank 1] eyes, itchy throat, sneezing, ___________[Blank 2] and stuffy nose. She has family history of __________[Blank 3]. She always struggled with many different allergies: dust, pollen, cat and dog __________[Blank 4]. She had tried different types of over-the-counter allergy ___________[Blank 5], but they didn’t help to alleviate the symptoms. She is currently taking Reactine 5 mg daily which does not relieve all of her symptoms.

PHYSICAL EXAMINATION: GENERAL: Patient is pale and in moderate ________[Blank 6]. VITAL SIGNS: Weight 160 pounds, B/P 120/80, ________[Blank 7] rate 90 beats per minute, respiratory rate 18 per minute, temperature 98.6 F. HEENT: EYES: Red, watery, itching, burning and swelling. EARS: Normal. NOSE: Mouth breathing, sneezing, runny and itchy nose, post-nasal _________[Blank 8], nasal congestion. THROAT: Itchy and swollen. CHEST: __________[Blank 9] and wheezing.

MEDICATIONS

1. Reactine 5 mg ________[Blank 10].
2. Escitalopram 20 mg q.d.
3. Lorazepam 0.5 mg p.r.n. nightly at bedtime.
4. Fenofibrate 145 mg q.h.s.

ASSESSMENT

1. Patient has severe seasonal allergic ___________[Blank 11].
2. Possible anemia.

PLAN

1. Recommended Reactive 10 mg q.d.
2. Referred to an allergist to provide patient more options for allergy treatments.
3. Ordered a blood work to check her ________[Blank 12] and cholesterol levels.
4. Follow up in 4 days to review her blood work results.

_________________________________
Trevor Sharpe, MD

Check your answers:^[2]

Fill in the following medical report using the words listed below:

• stones
•  fatigued
• fever
• tonsillitis
• temperature
• cervical
• dysphagia
• erythema
• crypts
• tonsillolith
• pseudomembranes
• tonsillectomy
• gargles

PATIENT NAME: Celine CAMERON
AGE: 16
SEX: Female
DOB: March 25
DATE OF ASSESSMENT: August 4
ATTENDING PHYSICIAN: Grant Talbot, MD, Pediatrics

HISTORY: This is a 16-year-old female today with complaints of throat pain. She has been struggling with inflamed tonsils for the last 2 weeks. The patient claims that tonsil ________[Blank 1] are forming and that a white film has appeared over their tonsils. She has been feeling very _________[Blank 2], has developed a mild ________[Blank 3] and occasionally feel nauseous.

The client has a family history of _________[Blank 4] resulting in tonsillectomy. She mentioned that her grandmother experienced recurrent tonsillitis around the same age. The condition of tonsillitis has occurred on 2 other occasions in the past 5 months.

PHYSICAL AND EXAMINATION: Ms. Cameron is in no acute distress. She appears fatigued. VITAL SIGNS: Blood Pressure 132/83, __________[Blank 5] is slightly elevated at 99.6, pulse 67. She is in generally in good condition. Throat palpation was performed. There is significant enlargement of the __________[Blank 6] lymph nodes. She appears to be experiencing ________[Blank 7]. Throat was examined and revealed swelling, ________[Blank 8] and tonsillar ________[Blank 9] visible. A ________[Blank 10] was seen to be forming within one of the crypts. Celine’s claims of ________[Blank 11] were also confirmed. She denies any symptoms such as a nasal discharge, cough, or abdominal pain. Throat was swabbed.

ASSESSMENT: Ms. Cameron appears to be experiencing recurrent tonsillitis correlated to exaggerated tonsillar crypts. Possible ___________[Blank 12] may be required.

PLAN

1. Patient was given a referral to an ENT specialist and may require tonsillectomy.
2. The patient was instructed to follow a diet of soft, smooth foods and soothing liquids.
3. It was suggested that the patient use saltwater ________[Blank 13] in the mornings and before bed.
4. A prescription of Amoxicillin 400 mg p.o. p.c.

___________________________________
Grant Talbot, MD, Pediatrics

Check your answers: ^[3]

Fill in the following medical report using the words listed below:

• dysphagia
• prescribed
• lymph
• enlarged
• ibuprofen
• erythromycin
• tonsillectomy
• surgery

PATIENT NAME: Jason MACDONALD
AGE: 7
SEX: Male
DOB: August 19
DATE OF ASSESSMENT: November 15
ATTENDING PHYSICIAN: Grant Talbot, MD, Pediatrics

DIAGNOSIS: Tonsillitis

HISTORY: This 7-year-old white male has been seen by me on several occasions over the last two years. He has complained of pharyngitis, ________[Blank 1], and fever. I have ___________[Blank 2] erythromycin in the past.

PHYSICAL EXAMINATION: When I examined Jason today, he once again had the same complaints as in the past. I also noticed that the ________[Blank 3] nodes in his neck were __________[Blank 4] and tender. He had a temperature of 39 degrees.

TREATMENT: I gave Jason _________[Blank 5] for his fever and prescribed _________[Blank 6] again.

PLAN: It is my recommendation that Jason undergo a _________[Blank 7]. Jason’s parents are in agreement. I will make the arrangements for Jason’s ___________[Blank 8].

_________________________
Grant Talbot, MD, Pediatrics

Check your answers: ^[4]