Patrick Platt

HISTORY AND PHYSICAL testing tolerant Name Patrick Platt Patient ID 771033 Room No 560 envision of Admission 08/30/- Admitting Physician William Payne, MD Admitting Diagnosis Rule out fracture of left over(p) arm. CHIEF COMPLAINT Pain and puffiness, left upper arm. HISTORY OF make ILLNESS The patient is an elderly male, who fell four days foregoing to admission. He noted immediate pain and swelling in the sphere just above his left elbow. He presented to the emergency room for treatment. yesteryear HISTORY Past illnesses include whooping cough as a child.Tonsillectomy in the past. No known totallyergies to medications. FAMILY HISTORY No hereditary disorders noted. Mother and produce are deceased. Two brothers are alive and well. One sister has adult-onset diabetes mellitus. genial HISTORY The patient is married and has two children. His wife does not kick the bucket outside the home. (No mention of tobacco or alcohol use). PHYSICAL EXAMINATION GENERAL The patient is a w ell-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, cellular respiration 18. HEENT Head sane, no lesions, Eyes, arcus senilis, both eyes. Ears, impacted cerumen, left ear. Nose, clear. Mouth, dentures run low well, no lesions. NECK Normal range of motion in all directions. (Continued) HISTORY AND PHYSICAL EXAMINATION Patient Name Patrick Platt Patient ID 771033 Date of Admission 08/30/- Page 2 INTEGUMENTARY Psoriatic lesion, right thigh, well-nigh 1 mm 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 bowel sounds. Liver, kidneys, and spleen are normal to palpation. GENITALIA Tests normally descended bilaterally. RECTAL Prostate 2+ and benign. EXTREMITIES Pain and swelling noted above the left elbow, other up per extremities normal. No cyanosis or clubbing. The legs demonstrate 2+ pitting edema to the knees.NEUROLOGIC Crainial nerves II through XII intact, memory intact, sensation intact to light touch. mind AND PLAN The patient was sent for plain film of the left arm, which revealed a fracture of the left humerus. The fracture was reduced in the emergency room. roentgen ray revealed anatomic alignment. He was released to home with a prescription for a nonsteroidal anti-inflammatory and instructions to elevate his arm. He will follow up in the office in three days. PROGNOSIS Good. _________________________ William Payne, MD WMR D08/30/- T09/01/-