Sunday, August 1, 2010

Dr. Write

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.