This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016after collecting informed patient consent (form downloadablehere) by our patient-information-communication-executive from pin-code-area 736 for a discussion initiated by patient's primary care physician in-charge:manage by jyoti tripathi and arjun solanky
70yrs old man with hypertension since 3_4month
Nam_xxx
Age/sex_ 70yr/M
__70_ yr old fe/male presents for ____ abd pain 2inch above umblicus...
Anxiety and vertigo during Bp High without medication...
Swelling on both limb (putting oedema)
History of Present Illness symptoms: pt complaining all complaint are gradual onset..
Swelling on both limb since 1yr.
Past Medical History:
Current Medications:
Medication allergies:
not specific
Social history _ good
Family History:no
O: (listed are the components of the all normal physical exam)
General: Well appearing,
Ambulating without difficulty.
Skin: Good ,no rash
Hair: Normal texture and distribution.
Nails: Normal color, no deformities
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable masses,
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric
Ears: TMs translucent & mobile, ossicles nl appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant
resorption.
Pharynx: Mucosa non-inflamed, no tonsillar
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
Heart: No cardiomegaly
Lungs: Clear to auscultation and percussion
Abdomen: Bowel sounds normal, tenderness,
Back: Spine normal without deformity or tenderness,
Rectal: Normal sphincter tone, no hemorrhoids or masses palpable
Extremities: deformities, edema in both limb
Musculoskeletal: Normal gait and station.
Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal
in upper and lower extremities. No pathologic reflexes.
normal mood
A:
Assessment:
Hypertension
P:
Laboratory:
X-Rays:
Medications:
T. Deriphylline
T. Chest on cold
T. Amlovas
Nebulazation with asthelin
