CHIEF COMPLAINT: Leg pain x
HISTORY OF PRESENT ILLNESS:
Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Nausea- , Vomiting- , SOB- , CP- , Sweating-
Recent injury-
Similar leg pain before-
ER Tx given-
Cough- , Fever/chills- , Skin rash- , Swelling- , Back pain-
Headache- , Vision problems- , Sore throat-
Abdominal pain- , Black/bloody stools- , Dysuria-
PAST MEDICAL HISTORY:
MI CAD HTN DM Low back pain DVT Cellulitis Gout
Catheterization Echo
Stroke CA PUD PVD COPD Asthma Gallstones
EGD Colonoscopy
PAST SURGICAL HISTORY:
Knee surgery Cholecystectomy Hernia GSW Hysterectomy
MEDICATIONS:
ALLERGY: NKDA
FMH:
CAD<> 55 yo DM Stroke HTN CA
SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol- no heavy occasional last drink
Smoker: no
Illicit drugs- no cocaine heroin marijuana
REVIEW OF SYSTEMS: unremarkable apart from above symptoms
PHYSICAL EXAM:
VITALS:
SpO2-
GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD
LUNGS: CTA (B)
HEART: Clear S1S2, RRR
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema
PERIPHERAL VASCULAR: palpable
NEURO:
AAO x 3
CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B)
DTR: ++DTR
SENSATION: non focal
CEREBELLAR: non focal
LABS:
N= B= L=
Blood Cx:
Urine Cx: UA: Sputum Cx:
Creatinine clearance=
XR:
CXR:
ASSESSMENT:
-Leg pain due to
*Cellulitis
*DVT-> Duplex -
*Lumbar radiculopathy
*Arthritis
PLAN:
-Blood cx x 2
-Unasyn
-CBCD, BMP in AM
-UA
-Tylenol 650 mg PO q 4-6 hr PRN pain/fever
-Home meds
-Heparin 5000 U SQ BID
Signature:
Created: 2/2005
Updated: 03/08/2007
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