GeneralHospitalAdmitNote

Date Time
11/11/09 14:00 InternalMedicineStudentNote
CC:SOB
Meds
HPI:65y/oMwithHxofCADandMIwithPCIin2006(stenttoLAD)
Lasix20mgpobid
lisinopril20mgpodaily
presentswithSOBx3days.Symptomsstartedsuddenlywhile
etc....... walkingupthestairsandlastedabout23minutes.Etc......
PMHxPSHxFHxSocialMeds(home)
CAD PCItoLAD F45MI smoke Lasix20mgpobid
GERD (2006) M98CVA alcohol lisinopril20mgpodaily
nexium40mgpodaily
CHF Cholecystectomy drugs etc........
HTN
MI(2006)
O/VS:T98.6HR86(7290)RR18(1820)BP132/84(120/80134/86)
Gen:NAD,AAOx3
HEENT:AT/NC,PERRLA,pinkconjunctiva
Heart:RRR,S1,S2,2/6holosystolicmurmuratapex,JVD
Lungs:CTAB/L
Abd:BSx4,soft,nontender,masses
Ext:c/c/e,+2pedalpulsesB/L
HgbNaClBUNPTPTT
Labs:WbcPltGlucoseINR
HctKCo2CrpH/SpCO2/SpO2/bicarb/O2sat
Tele:NSRwithPVCs
EKG:LAD,qwaveinV2,V3,V4
Rads:CXR:Cardiomegaly,effusions,pnuemothorax

A/P
1)SOBpossibly2toCHForPE,ischemicchangesonEKGtosuggest
acutecoronarysyndrome,CE()x3.Willorderechotofurtherevaluateas
wellasCTangiogramtoruleoutPE.Cardiologyconsulted.
2)CHF2toischemiccardiomyopathy,maybecauseofsymptoms
howeverptisclinicallyeuvolemic,echoandcardioconsultpending
3)HxHTNcontrolled,continuetreatment
4)HxGERDptcurrentlyonNexium,continuetreatment