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PHYSICAL EXAMINATION: Vital signs temperature 36.7. Pulse 64. Respiration 20. Blood pressure 134/76. Pulse oximetry 94%. Patient does have oxygen onright now. HEENT: Eyes Perla fundoscopic WNL. EARS: Clear. NOSE: Peyton. THREW UP: Negative. NECK: Supple. No masses. Carotids +1 bilaterally. No brewing. LUNGS: Clear to P&A. HEART: Regular. No members or ectopy. ABDOMEN: Good bowel sounds. Soft no masses or tenderness. Femoral Pulses 1+ bilaterally. No inguinal lymphadenopathy. No coastal vertebral angles tenderness. GENERAL RENTAL: Normal. Male genitalia with both testes descended. RECTAL: Deferred. EXTREMITIES: No edema or cyanosis dorsalis pedis 1+ bilaterally. NEUROLOGIC CELEBRATION: Clear. CRANIAL: Nerves intact motor and sensory symmetrical in the upper and lower. EXTREMITIES: Deep tendon reflexes 2+ bilaterally upper and lower. No ankle clonus Babinski both down going.RADIOLOGY DATA: CT of the abdomen and pelvis does reveal a 5mm stone atthe right ureteropelvic junction. The rest of the CT scan looked fine.DIAGNOSIS: The right stone at the ureteropelvic junction. History of hyperuricemia. Gout asymptomatic. Hypertriglyceridemia hypercholesterolemia. History of tubulovillous adenomatous colon polyps, which have been followed by two colonoscopies. PLAN: Admit to Urology ED, notify Dana Kelly of console. Continue IV fluids, Dilaudid IV medications to control his nausea, refer to the cart for that. KUB this morning to see if there is any progression of the stone. He can be up so that hopefully the stone will move. We will see how he was tomorrow and go from there. HISTORY AND PHYSICAL EXAMINATION
Taylor Cohn 0686904OST241NW1Quali-Care Case 1Patient Name: Crawford D. BabbPatient ID: 16-7341Date of Admission: 08/05/xxPage 3_____________________________________Connie Wilder, MD, Emergency MedicineCW: xxD: 08/05/xxT: 08/05/xxC: Dana Kelly, MD, UrologyAnderson Phipps, MD, Family MedicineDoris Robertson, MD, Gastroenterology