Tim

 

Name: Tim Davis

Age: 42 yrs. Male

Allergy: NKDA

Height:71

Temp: 38.6 (101.5F) oral

PULSE: 102 bpm regular rhythm strength normal

B/P:  114/62 left, 114/62 right, normotensive, Pulse pressure: normal

Orthostatic B/P: 94/50mmg upon standing

Resp: 14 bpm rhythm, effort unlabored

Spo2: 94%

Weight: 82.7kg (180.0 lbs.)

BMI: 25.1

Cog Status: A and O X 4

HEENT/NECK: Good dentition thyroid within normal limit for size and size and consistency, no cervical lymphadenopathy or mass.

Cardiovascular: regular rhythm and rate no murmur or gallop, no peripheral edema

Chest/ respiration: thorax normal to percussion, breath sound equal / clear bilaterally

Abdomen: non distended, no hepatosplenomegaly, mass or herniation, soft, non-tender throughout

Neurologic: reflexes 2 +bilaterally throughout CN ll-Xll intact

Musculoskeletal: normal muscle tone and bulk bilaterally

Genitourinary: normal muscle tone and bulk bilaterally

Genitourinary/rectal: normal circumcised prostate normal

 Immunologic: normal

Skin: no pallor jaundice, ecchymoses, or rash, no gynecomastia

Lymphatic: no adenopathy

Hematologic: no ecchymosis, no petechiae

History mgt / plan: lipid panel done

Result:

Cholesterol: 239mg/dL (low risk <200, moderate 200-239, high risk >239)

HDL: 52unit dL ( maj risk < 40, Neg risk > 59)

LDL:152unit/L (Low risk < 130, moderate 130-159, high risk >159)

Triglyceride: 175mg/dL (35-135, high risk 40-160)

Follow up: Called Mr. Davis with result

Cholesterol borderline elevation

Cholesterol lowering diet recommended.

 

 

Chief complain/complain: Terrible watery diarrhea that start 3 days ago and he just feel wipe out, he went every 2hours, headache and mouth feel like someone stuck bunch of cotton in it.

Skin: Warm and mildly diaphoretic

Pain: A bit all over the head

 Diarrhea: Most distressing start 3 days ago., 8 times per day tried some meds but no work

Hematuria: Streak of blood in the stool last time an hour ago, stomach feel sore and painful

Diarrhea: Nothing makes it better or worse, haven’t slept much at all in 36 hours

Headache: Same time as diarrhea but not sure, inside /deep headache

Nausea and vomiting: Not throw up at all

Abdomen: Stomach feel sore and crampy comes and go

Preventative health: Biannual dental cleaning with annual dental exam

Immunization: Up to date including seasonal flu

 Past medical history: childhood illness: chicken pox, adult illness : none, multiple bouts of diarrhea of unclear etiology with no studies done.

Family history: Father 68 healthy except for mild hypertension controlled by medication, mother 67 healthy with no current medication, children 8yrs and 12 both healthy

Social history: Partner in direct marketing company that publisher variety of health-related magazine, married with 2 children live in a house in Westchester, no pet, never smoke, for alcohol take 1 glass of wine 3 to 4 night weekly, sexual history: 4 sexual partner all women prior to meeting his wife   at age 26, monogamous since then