Patient Name:  Smith, Brian

Patient ID:8485758

Admission Date: 4/13/xx

DOB: 04/20/XX

Chief Complaint: Back Pain

History of Present Illness: Brian Well is a 66yr old who was admitted for 360 spinal fusion.  

 

Medical History:  HTN, chronic back pain

Medications: norvasc, morphine, dilaudid, prilosec, colace, singulair

Allergies: Sulfa, Codeine, Morphine


Social History: He does not drink, he quit smoking 30 years ago

Family History: Married with 4 children

Physical Examination:

General:  This is a male who is alert and oriented x3, Ht: 65 in Wt: 70 kg

Vital Signs: Blood Pressure 160/90, heart rate 90, Respiration 20, Temperature 97.2°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 tender

Genitourinary: Unremarkable

Rectal: Unremarkable.                                  

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

Laboratory and X-ray Data: sodium 137, Potassium 4.6, glucose 100, BUN 13, creatinine 0.9, white count 7600, Hemoglobin 14.1, Hematocrit 41.3, platelets 283. 

 

Impression:

  1. Compression of L4-L5 

Plan:

  1. Admit to Med-Surg
  2. Spinal Fusion
Last modified: Wednesday, April 1, 2020, 8:39 AM