CC: SOB and Abd pn.
HPI:
65 y-o WM w/ hx of CHF, CAD, IDDM, Htn, &SLE was admitted @BMC c/o CP, SOB, LUE edema and UTI for 7 days. Pt. also c/o no BM for 1 wk. and + LGIB. Pt. also c/o abd. Pn and N&V for 2 wks. (-) flatus x 3 days.
PMH:
As in HPI. + CHF, CAD, s/p CABG, LGB, BIH and ORIF LH.
NKA
MEDs: see list.
FH:
n/c
SH:
Cig: 2 ppd x 30 yrs. Etoh (-) ret.
ROS:
See HPI
PE:
VSS, AF
HEENT: NC/AT, PERRLA, EOM’s nl,
Neck: NT, (-) Br.
Pul.: Cl. To A &P
CVS: RRR, nl S1S2 w/o m, S3 S4, (-) JVD
Abd: (+) BS, w/o HSM, B9
Rectal: WNL
Ext: w/o C, C, E, pulses 2+
Neuro: NLS
A/P:
65 yo WM w/ MM Probs. Plan CT A/P, CXR, EKG, CC cath.
Consult GS, Card, GI, Pulm.
CCM.
I will happily accept any one's translation of this perfectly plausible History and Physical.
Chief Complaint: Shortness fo Breath and abdominal pain
ReplyDeleteHistory of Present Ilness: 65 year old white male with history of congestive heart failure, coronary artery disease, Diabetes, hypertension, and systemic lupus erythematosis was admitted to B Medical Center complaining of chest pain, shortness of breath, left upper extremity edema and urinary tract infection for 7 days. Patient also complains of no bowel movement for one week.
patient also complains of abdominal pain and nausea and vomiting for two weeks. No flatus for three days.
Past Medical History: As in History of Present Illness.Positive for congestive heart failure, coronary artery disease, status post coronary artery bypass graft, bilateral inguinal hernia and open reduction with internal fixation of left hand. No known allergies.
Medications:See list
Family History: Non contributory
Social History: Smokes 2 packs per day for 30 years. No alcohol use
Review of Systems: See History of Present Illness
Physical Examination:
Vital signs stable, afebrile.
Head, eyes, ears, nose throat: Normocephalic, atraumatic, pupils equal round react to light and accommodation, extraocular motions intact
Neck: Nontender, no bruit
Pulmonary: Clear to percussion and auscultation
Cardiovascular: Regular rhythm, normal first and second heart sounds, without murmur or second and third heart sounds, negative jugular venous distension
Abdomen: Bowel sounds present, benign
Rectal: Within normal limits
Extremities: Without claudication or edema. Peripheral pulses intact.
Neurologic: No long tract signs.
Assessment and Plan: 65 year old white male with multiple medical problems. Plan computed tomography of abdomen and pelvis,chest xray, electrocardiogram, cardiac catheterization, Consult Cardiology, gastroenterology, pulmonary and critical care medicine services.
It doesn't matter. No one reads them anyway.
What E&M can we use?
BR Gelber neurosurgeon
pretty good, but you forgot HSM (hepatosplenomegaly), WNL probably really means "We never Looked"
ReplyDeletewhat is lgib?
ReplyDeleteLower GI Bleeding
ReplyDelete