History.docx - HISTORY AND PHYSICAL EXAMINATION Patient...

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HISTORY AND PHYSICAL EXAMINATION Patient Name : Chapman Robert Kinsey Patient ID : 110589 DOB : 07/04 Age : 87 Sex : Male Room No. : 322-B Date of Admission : 02/23 Admitting Physician : Martha C. Eaton, MD, Geriatrics Chief Complaint : Admitted from Dr. Max Hirsch’s office due to deep ulcer on left toe. Admitting Diagnoses : 1. Severe peripheral vascular disease, status post deep ulcer on left toe. Rule out thrombolysis. The patient was admitted to a regular floor. Condition is serious. 2. ALLERGY TO PENICILLIN, which puts patient into anaphylactic shock. 3. Continue with home medications. Details of Present Illness : Mr. Kinsey is an 87-year-old white gentleman with history of (1) Chronic atrial fibrillation, on Coumadin. (2) Chronic deafness, bilateral. (3) Severe peripheral vascular disease. (4) Status post left endarterectomy done in November of last year. (5) Chronic renal failure. (6) Status post right great toe amputation secondary to peripheral vascular disease.
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  • Fall '17
  • Beverly Vickery

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