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History and Physical (H and P) Medical Transcription Transcribed Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:  Altered mental status.

ADMITTING DIAGNOSES:
1.  Altered mental status.
2.  Abnormal EKG, rule out acute coronary syndrome.

HISTORY OF PRESENT ILLNESS:   This is a very unfortunate (XX)-year-old male whom the neighbors called the police on, as they had not seen the patient for several days.  The neighbors yesterday had knocked on the door and there was no answer.  They knocked on the door again today.  When there was no answer, they called the police to check on him.  The police entered the patient's home and found the patient to be very confused.  He appeared emaciated.  The patient was brought to the emergency department for further evaluation.

PAST MEDICAL/SURGICAL HISTORY:  Unable to obtain directly from the patient due to confusion.  However, from old records, was admitted for a lower GI bleed and urinary retention in the past.  There is a stated history of hypertension and BPH, status post TURP, also a history of a severe motor vehicle accident when he was a teenager.

FAMILY HISTORY:  The patient was unable to provide.  He was able to state that he is unmarried with no children.  He has, he says, relatives in the area but was unable to remember any of their names or phone numbers.  He did not have any information pertaining to his parents or whether or not he had any siblings.

SOCIAL HISTORY:  The patient was a long-standing smoker, smoking half a pack per day for over 20 years.  The patient denied any alcohol abuse or illicit drug use in the past; however, this cannot be reliable due to his state of confusion.

MEDICATIONS:  Prior to admission are unknown.  Due to the fact that the patient has never been at this facility before and with his confusion, he was unable to say what medications he was on.

ALLERGIES:  UNKNOWN.

REVIEW OF SYSTEMS:  Probably unreliable due to the patient's confusion.  However, when questioned, the patient denies any history of recent headache, blurred vision, sore throat, fever, chills, chest pain, palpitations, shortness of breath or congestion.  Denied any abdominal pain.  It was noted by staff that the patient was incontinent of urine when he came to the ER.  The patient did state that he had some discomfort of his right foot with some swelling.  He denied any fainting, blackouts or seizures.  Denied any one-sided weakness or difficulty with speech.

PHYSICAL EXAMINATION:  Please refer to the chart.

LABORATORY DATA:  Please refer to the chart.

ADVANCED DIRECTIVES:  Unknown.  The patient will remain a FULL CODE.  At this time, it is unknown as to whether he had a prior health care proxy.  We will consult with social services to attempt to contact any living family members for further information.

ASSESSMENT AND MEDICAL DECISION MAKING:
1.  Altered mental status, dementia versus delirium.  CT was negative for bleed.  There was some suspicion for evolving infarction.  MRI was recommended due to the fact that there are no neuro deficits at this time other than some confusion.  We will have a neuro consult in the a.m.
2.  Abnormal EKG, rule out acute coronary syndrome.  The EKG done upon patient's arrival showed normal sinus rhythm, in the 80s, with a possible inferior and anterior infarct and T wave abnormalities in lateral leads suggestive of ischemia.  That was done at 1900.  Had the EKG repeated in the ER, which showed the same findings; although, in the lateral leads, T wave inversions were a little more pronounced.  The patient does have history, seen in the old records, of left ventricular hypertrophy.  I consulted with the cardiologist, who was in the ER at the time, who stated that EKG changes with the patient being totally asymptomatic could be related to severe LVH, so the plan is to admit the patient on telemetry.  We will continue with serial enzymes.  The patient could be started on a low-dose beta blocker, aspirin, subcutaneous Lovenox.  Repeat EKGs daily x3 days.  O2 at 2 liters via nasal cannula.  We will do a fasting lipid profile in the morning and start a statin if appropriate.  We will order an echocardiogram for the morning to evaluate left ventricular ejection fraction, which on echo that was done 7 years ago showed a normal ejection fraction, and have a cardiology consult in the morning.
3.  Hypertension.  According to the old records, the patient has a past history of hypertension.  In the past, he was discharged home on atenolol, but the patient could not remember being on medications at this time, but in light of EKG changes, we will put him on low-dose beta blocker as stated above.  The chest x-ray showed some mild congestion, and the patient does have edema in his feet and ankles so we will also add hydrochlorothiazide for blood pressure control and edema.
4.  Gastrointestinal/deep venous thrombosis prophylaxis.  The patient has a history of GI bleeding in the past.  His hemoglobin and hematocrit are stable at this time.  We will start the patient on Protonix p.o. daily, and as stated in #2, the patient will be on subcutaneous Lovenox for anticoagulation therapy.
5.  Advanced directives.  The patient is a FULL CODE with no health care proxy at this time.  The patient states he has no children.  We will have social services in consult to attempt to contact any family members, as the patient states he has many relatives in the area.

Further clinical decision making will be based on further diagnostic studies.

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