Patient ID: 3487742

Admission Date: 2/14/XX                

DOB: 2/20/XX

Chief Complaint: Chest Pain

 

History of Present Illness: Ms. Baal is a 82 year old female who presented to the ER with chest pain and slight confusion.  She was admitted for observation.

 

Medical History:  T/A 1970, NIDDM, A-Fib, HTN

 

Medications: Digoxin, Lasix, lisinopril, glucophage

 

Allergies: Morphine

 

Social History: She does not drink and quit smoking 30 years ago.

 

Family History: Married with 2 children.  Father died of MI. 

 

Physical Examination:

General:  This is a overweight female who is alert and oriented x 3

Diet: 1800 ADA

Vital Signs: Blood Pressure 110/88, heart rate 88, Respiration 18, Temperature 98.2°F

HEENT: Clear

Lymph: Unremarkable

Neck: No goiter, no jugular venous distention

Chest: Clear

Heart: Regular rate and rhythm, no murmur, rub or gallop

Abdomen: Soft and nontender

Genitourinary: nontender

Rectal: Unremarkable.                                   

Skin: pink, moist mucous membranes. Skin turgor within normal limits.

 

Laboratory and X-ray Data: sodium 140, Potassium 3.8, glucose 90, BUN 15, creatinine 1.0, white count 7000, Hemoglobin 14.2, Hematocrit 45, platelets 210.  Cardiac Markers within normal limits

 

Impression:

  1. Possible MI

 

Plan:

  1. Admit for Observation
Last modified: Monday, March 23, 2020, 10:24 AM