Hillcrest Medical Complete Case 9
HISTORY AND PHYSICAL
Patient Name: Marilyn Sue Stone
Patient ID: 116588 DOB: 01/24 Age: 50 Sex: F
Room No.: 181A
Date of Admission: 02/07/2012
Admitting Physician: Jessie D. Smith, MD of Orthopedics
Admitting Diagnosis: Chronic Hip Pain
HISTORY OF PRESENT ILLNESS: Patient is a candidate for a total right hip revision. She has 2 units of directed packed red blood cells. It is not autologous. She does had Hepatitis B. She has arthrogryposis. She had a right total hip replacement many years ago by Dr. Dodd at the University of Miami. She has had multiple other surgical procedures as follows. A: She had bilateral foot surgery In the remote past. B: She had left hip surgery a year ago. C: She had right foot surgery in the remote past. D: She had left foot surgery in the remote past at Hillcrest by Dr. Smith, myself. E: She had right hip surgery 28 years ago. F: She had left hip surgery 26 years ago. G: 17 years ago she had a stage 2 left hip procedure completed 15 years ago. H: She had left hip revision 12 years ago. I: Nine years ago she had a mass on the bottom of her foot removed by Dr. Shelton of Podiatry .
SOCIAL HISTORY: She works in the medical field. Enjoys a healthy social life, lives alone, is single, is nulliparous. She has Hepatitis B core antibody.
ALLERGIES: Patient is allergic to penicillin, codeine, secphlis sporens and Demerol.
MEDICATIONS: Spironolactone 25mg, 2.5 per day, Verapamil ER 240mg, 1.5 per day. Zoloft 50mg 1.5 per day. Study drug for osteolysis Nasacort and Darvocet n100 q4h p.r.n. pain. Has taken Allegra 180mg daily, Calcium and multivitamins.
REVIEW OF SYSTEMS: HEENT: WNL. CARDIOPULMONARY: No history of cardiac disease, chest pain, shortness of breath or rhythm abnormality. MUSCLOSKELTEAL: See history of present illness.
(Continued)
NEUROLOGIC: History of migraine headaches, otherwise WNL.
PHYSCIAL EXAMINATION: In general the patient is a very nice 50 year old lady. She is
Patient Name: Marilyn Sue Stone
Patient ID: 116588 DOB: 01/24 Age: 50 Sex: F
Room No.: 181A
Date of Admission: 02/07/2012
Admitting Physician: Jessie D. Smith, MD of Orthopedics
Admitting Diagnosis: Chronic Hip Pain
HISTORY OF PRESENT ILLNESS: Patient is a candidate for a total right hip revision. She has 2 units of directed packed red blood cells. It is not autologous. She does had Hepatitis B. She has arthrogryposis. She had a right total hip replacement many years ago by Dr. Dodd at the University of Miami. She has had multiple other surgical procedures as follows. A: She had bilateral foot surgery In the remote past. B: She had left hip surgery a year ago. C: She had right foot surgery in the remote past. D: She had left foot surgery in the remote past at Hillcrest by Dr. Smith, myself. E: She had right hip surgery 28 years ago. F: She had left hip surgery 26 years ago. G: 17 years ago she had a stage 2 left hip procedure completed 15 years ago. H: She had left hip revision 12 years ago. I: Nine years ago she had a mass on the bottom of her foot removed by Dr. Shelton of Podiatry .
SOCIAL HISTORY: She works in the medical field. Enjoys a healthy social life, lives alone, is single, is nulliparous. She has Hepatitis B core antibody.
ALLERGIES: Patient is allergic to penicillin, codeine, secphlis sporens and Demerol.
MEDICATIONS: Spironolactone 25mg, 2.5 per day, Verapamil ER 240mg, 1.5 per day. Zoloft 50mg 1.5 per day. Study drug for osteolysis Nasacort and Darvocet n100 q4h p.r.n. pain. Has taken Allegra 180mg daily, Calcium and multivitamins.
REVIEW OF SYSTEMS: HEENT: WNL. CARDIOPULMONARY: No history of cardiac disease, chest pain, shortness of breath or rhythm abnormality. MUSCLOSKELTEAL: See history of present illness.
(Continued)
NEUROLOGIC: History of migraine headaches, otherwise WNL.
PHYSCIAL EXAMINATION: In general the patient is a very nice 50 year old lady. She is