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Admit Note PDF
Admit Note PDF
Date Time
11/11/09 14:00 Internal Medicine Student Note
CC: SOB
Meds
HPI: 65 y/o M with Hx of CAD and MI with PCI in 2006 (stent to LAD)
Lasix 20mg po bid
lisinopril 20mg po daily
presents with SOB x 3 days. Symptoms started suddenly while
etc....... walking up the stairs and lasted about 23 minutes. Etc......
PMHx PSHx FHx Social Meds(home)
CAD PCI to LAD F↓45 MI Ø smoke Lasix 20mg po bid
GERD (2006) M↑98 CVA Ø alcohol lisinopril 20mg po daily
nexium 40mg po daily
CHF Cholecystectomy Ø drugs etc........
HTN
MI (2006)
O/ VS: T – 98.6 HR – 86(7290) RR – 18(1820) BP 132/84(120/80134/86)
Gen: NAD, AAOx3
HEENT: AT/NC, PERRLA, pink conjunctiva
Heart: RRR, S1, S2, 2/6 holosystolic murmur at apex, ØJVD
Lungs: CTA B/L
Abd: BSx4, soft, nontender, Ø masses
Ext: Ø c/c/e, +2 pedal pulses B/L
Hgb Na Cl BUN PT PTT
Labs: Wbc Plt Glucose INR
Hct K Co2 Cr pH/SpCO2/SpO2/bicarb/O2 sat
Tele: NSR with PVCs
EKG: LAD, q wave in V2, V3, V4
Rads: CXR: Cardiomegaly, Ø effusions, Ø pnuemothorax
A/P
1) SOB – possibly 2° to CHF or PE, Ø ischemic changes on EKG to suggest
acute coronary syndrome, CE () x 3. Will order echo to further evaluate as
well as CT angiogram to rule out PE. Cardiology consulted.
2) CHF – 2° to ischemic cardiomyopathy, may be cause of symptoms
however pt is clinically euvolemic, echo and cardio consult pending
3) Hx HTN – controlled, continue treatment
4) Hx GERD – pt currently on Nexium, continue treatment