Documente Academic
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Documente Cultură
Date: 04-10-07
Past medical history is unchanged from that previously noted. He did stop
taking his Lisinopril independently without recommendation from the
physician. His remaining past medical history, family history, social history,
a view of systems is unchanged from prior exams except as noted above.
OBJECTIVE:
Physical Examination:
Vital Signs: Pulse – 84 and regular, Respirations – 20, Blood Pressure –
145/80 (RUE), Weight – 170 to 175 lbs. (by patient’s report).
HEENT: unremarkable with no oral lesions, no abnormalities with his eyes or
ears.
Neck: supple without JVD or bruits, there is no adenopathy either in his jugular
chain bilaterally or the supraclavicular or infraclavicular areas bilaterally.
Chest and Pulmonary: clear with no rales or rhonchi, no wheezing or rubs;
decreased breath sounds diffusely as noted previously.
Heart: Heart sounds are normal with grade 3-4/6, holosystolic murmur at lower
left sternum border radiating to apex and axilla. There is no gallop, rub,
heave or lift.
Abdomen: Unremarkable with no masses, tenderness or organomegaly. His
abdominal pulsation in the midline seems to be slightly more prominent then
it was 2 months prior, but no discreet aneurysm is present.
Rectal: deferred
GU: deferred
Extremities: Full range of motion with pulses unchanged being 4+ in the upper
extremities, 4+ femoral, popliteal and 4+ pedal pulses except for his right
dorsalis which is 0 - 1.
Neuro: grossly intact, with no focal signs; cranial nerves intact.
ASSESSMENT:
COPD with recent episode of pneumonia – needs F/U CXR, possible CT
Scan, possible Bronchoscopy
1) Mitral Regurgitation (more prominent MR murmur) – needs F/U echo
2) CAD – may need F/U stress thallium / stress echo
3) Hematuria – F/U by local and NY urologists
4) AAA – needs Abdominal U/S
5) C. Diff Enteritis – currently inactive
PLAN:
Mr. Harrington is to return to New York within the next 2-3 weeks.
He is to be seen by his local physician for follow up for a number of these
issues and these were discussed in detail with him. He is to see his
local urologist later this week.
Specifically: COPD with pneumonia (R/O CA), Mitral Regurgitation, CAD,
Hematuria, C. diff. enteritis, Possible AAA