proofreading
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Patrick Platt
Patient ID: 771033
Room No.: 560
Date of Admission: 08/30/----
Admitting/Attending Physician: William Payne, MD
Admitting Diagnosis: Rule out fracture of left arm.
Chief Complaint: Pain and swelling, left upper arm.
HISTORY OF PRESENT ILLNESS: The patient is an elderly female who fell four days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He presented to the emergency room for treatment.
PAST HISTORY: Past illness includes whooping cough as a child. Tonsillectomoy in the past. No known allergies to medications.
FAMILY HISTORY: No hereditary disorders noted. Mother and father are deceased. Two brothers are alive and well. One sister has adult-set diabetes mellitus.
SOCIAL HISTORY: He is married and has two children. His wife does not work outside the home.
PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm. VITAL SIGNS: Blood pressure 140/90, temperature 98.3 degrees Fahrenheit, pulse 97, respiration 18.HEENT: Head normal, no lesions. Eyes, arcus senilis, both eyes. Ears, impacted cerumen, left ear. Nose, clear. Mouth, dentures fit well, no lesions. NECK: Normal range of motion in all directs. INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mL in diameter. CHEST: Clear breath sounds bilaterally. No rales or rhonchi noted. HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted. ABDOMEN: Normal bowl sounds. Liver, kidneys, and spleen are normal to palpitation. GENITALIA: Tests normally descended bilaterally. RECTAL: Prostate 2+ and benign. EXTREMITIES: Pain and swelling noted above the left elbow, other upper extremities normal. No cyanosis or clubbing. The legs demonstrate 2+ pitting
(Continued) edema to the knees. NEUROLOGIC:
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Patrick Platt
Patient ID: 771033
Room No.: 560
Date of Admission: 08/30/----
Admitting/Attending Physician: William Payne, MD
Admitting Diagnosis: Rule out fracture of left arm.
Chief Complaint: Pain and swelling, left upper arm.
HISTORY OF PRESENT ILLNESS: The patient is an elderly female who fell four days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He presented to the emergency room for treatment.
PAST HISTORY: Past illness includes whooping cough as a child. Tonsillectomoy in the past. No known allergies to medications.
FAMILY HISTORY: No hereditary disorders noted. Mother and father are deceased. Two brothers are alive and well. One sister has adult-set diabetes mellitus.
SOCIAL HISTORY: He is married and has two children. His wife does not work outside the home.
PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm. VITAL SIGNS: Blood pressure 140/90, temperature 98.3 degrees Fahrenheit, pulse 97, respiration 18.HEENT: Head normal, no lesions. Eyes, arcus senilis, both eyes. Ears, impacted cerumen, left ear. Nose, clear. Mouth, dentures fit well, no lesions. NECK: Normal range of motion in all directs. INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mL in diameter. CHEST: Clear breath sounds bilaterally. No rales or rhonchi noted. HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted. ABDOMEN: Normal bowl sounds. Liver, kidneys, and spleen are normal to palpitation. GENITALIA: Tests normally descended bilaterally. RECTAL: Prostate 2+ and benign. EXTREMITIES: Pain and swelling noted above the left elbow, other upper extremities normal. No cyanosis or clubbing. The legs demonstrate 2+ pitting
(Continued) edema to the knees. NEUROLOGIC: