INPATIENT - INITIAL VISIT
Chest Pain Admission H&P *
Patient:
SEX: Female
AGE: 44 years
Private Payer (Medicare rules for 65 and older)
DATE OF SERVICE: 1/1/20XX
Associated Diagnoses: None.
Basic Information
Source of history: Family member.
Present at bedside: Family member.
Referral source:
Chief Complaint: Patient is a female with acute hypoxia during hysteroscopy, EKG changes & troponin elevation to > 6. Intubated & on decreasing FI02. PH Morbid obesity, type 2 DM s/p gastric bypass, 50 lb weight loss. FH 2 siblings with blood clotting disorder on Rx. Now on Lovenox, rectal ASA, PRN IV Metoprolol.
Review of Systems:
Constitutional: Negative, except as documented in history of present illness.
Ears/Nose/Mouth/Throat: Negative.
Respiratory: Remote smoker 15 Y ago.
Cardiovascular: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Endocrine: Negative.
Immunologic: Negative.
Musculoskeletal: Negative.
Integumentary: Negative.
Neurologic: Negative.
Psychiatric: Negative.
All other systems are negative.
Health Status
Problem List:
All Problems:
Gastric bypass / 2819423013 / Confirmed
General finding of language and communication / 429020019 / Confirmed
General observation of patient 443466017 / Confirmed
Nursing observation AND/OR diagnosis 169649010 / Confirmed
Nutrition alteration / 1220901019 / Confirmed
Safety observations / 1222811017 / Confirmed
Spiritual distress / 213839019 / Confirmed
Active Problems (7)
Gastric bypass
General finding of language and communication
General observation of patient
Nursing observation AND/OR diagnosis
Nutrition alteration
Safety observations
Spiritual distress
Histories:
Past Medical History:
Active: Gastric bypass (2819423013)
Physical Examination
Eye: Sedated on Propofol.
Intake and Output
+4 L last 23 hr.
Cardiovascular: VP+2=4 cm
Health Maintenance
EKG S Tach, extensive ST depression. Today, reversal above now long QT. No Q waves. ECH sever hypokinesis most of LV with exception normal apex. Mild MR Increase RA press. Labs noted. K+ 3.3 on replacement.
Impression and Plan
Non STEMI
P; R & L heart cath.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX