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COVENANT --- Dr. AHN --- FORMAT=Separate paragraphs (not ROS or PX)

CHIEF COMPLAINT: Left flank pain.

HISTORY OF PRESENT ILLNESS: This 43-year-old white male developed pain
in the left flank last night, this was associated with nausea, several
episodes of emesis and diaphoresis. The pain got worse this morning and
radiated anteriorly into the left lower quadrant. He took a Lortab for
the pain without benefit. Denies any gross hematuria. This gentleman
had multiple episodes of kidney stones in the past and was treated with
lithotripsy without success on November 1999. The other three times the
stone passed spontaneously.

PAST MEDICAL HISTORY: Positive for hypertension.

ALLERGIES: No known allergies.

PRESENT MEDICATIONS: Hydrochlorothiazide, Lortab.

PHYSICAL EXAMINATION: This is a 43-year-old white male who is husky
built and morbidly obese and does not appear to be in acute distress.
VITAL SIGNS: Blood pressure 145/84, pulse 88, respirations 24,
temperature 97.9. HEENT: Unremarkable. NECK: Unremarkable. LUNGS:
Clear. HEART: Normal sinus rhythm, no murmurs. ABDOMEN: Soft, flat
and non-tender. No masses or organomegaly. Bowel sounds are normal.
SKIN: The skin is warm and dry. No cyanosis, no diaphoresis. No
rashes, petechiae or purpura noted. BACK: No CVA tenderness.
EXTREMITIES: Pulses equal and adequate in upper and lower extremities.
Range of motion intact and normal. Motor and sensory intact and normal.
DTR's +2 and equal. Capillary refill intact and normal. No edema, no
swelling.

Urinalysis was negative. CBC, Chem-7 were ordered and results are
pending. IVP is normal.

EMERGENCY DEPARTMENT COURSE / MEDICAL DECISION MAKING: The patient stated that the pain completely resolved approximately 30 minutes after
he received Toradol 60 mg and Inapsine 2.5 mg IV. Now he is pain free.
He was then allowed to go home with instructions to increase oral
fluids, strain the urine. Follow-up with Dr. Kim. Return here for any
further problem. I do believe the patient probably passed a stone while
he was laying in the x-ray table. The patient was discharged in stable
condition at time of discharge from the Emergency Department.

ST LUKES - DR SATONICK

CHIEF COMPLAINT: Chest pain.

HISTORY OF PRESENT ILLNESS: Sixty-five-year-old female who about ten
days ago was hospitalized with atrial fibrillation and rapid ventricular
response and probable non Q-wave event. Went on to follow on
catheterization which showed some 30% and 40-50 percent lesions in the
anterior descending. Over the last couple of days she has had a very
circumscribed high left chest pain, somewhat worse with movement. She
is not on sublingual Nitro. She does wear a Nitro patch. She has had
no real shortness of breath. No cough. No fevers. No chills. No
diaphoresis. No nausea, vomiting or diarrhea. The pain is
somewhat worse with activity and does seem to ease off with rest by her
report.

PAST MEDICAL HISTORY: As previously described in the history of present
illness in addition to hypothyroidism and hypertension.

ALLERGIES: Listed as none.

PRESENT MEDICATIONS: Aspirin, Nitro-dur, Metroprolol, Prempro,
Synthroid and Cardizem.

SURGICAL HISTORY: Remarkable for a recent heart cath and back surgery.

FAMILY HISTORY: Negative for premature coronary disease.

REVIEW OF SYSTEMS: Constitutional, no fever, chills, weight loss, weight gain. Ocular, no visual loss or visual change. ENT, no congestion. No dysphasia. Cardiovascular, see history of present illness. Pulmonary, no cough, wheeze, shortness of breath. Gastrointestinal, no nausea, vomiting, diarrhea. Genitourinary, no frequency, urgency or dysuria. Neuro, no headache or focal motor weakness, paresthesias or anesthesias. Musculoskeletal, no muscle pain, joint pain or trauma injury. Endocrine, no polyuria, polydipsia, polyphagia. Hematologic, no wheezing, bruising or bleed. Psychiatric, no auditory or visual hallucinations. No sleep disturbance.

PHYSICAL EXAMINATION: Afebrile. Resting heart rate is 73. Blood pressure 138/66. Respiratory rate 20. O2 SAT's are 97-98 percent. HEENT: The cranium is intact. Her tympanic membranes are clear. Her pupils are equal and reactive to light. Her extraocular muscles are intact. Her discs are sharp and clear. Her nares are patent without congestion. Her oropharynx reveals no injection or exudate. Mucous membranes are moist. Tongue and uvula rectal examination midline. Neck is supple without nodes or bruits, jugular venous distention or thyromegaly. LUNGS: Lungs are clear to auscultation without wheezes, rales or rhonchi. There is no CVA tenderness. HEART: Heart reveals a regular rate without murmurs, gallop, clicks or rubs. ABDOMEN: Abdomen is soft, non-tender. Bowel sounds are present in all four quadrants. EXTREMITIES: Extremities, no crepitus or deformity. Motor strength in symmetrically 5/5. Deep tendon reflexes are 2/4. Babinski's are downgoing bilaterally.

EMERGENCY DEPARTMENT COURSE AND DECISION: IV line was initiated supplemental to patient already taking aspirin. Two inches of Nitro paste was applied. She did have some mild discomfort when I examined her. Old records were called for and reviewed. Significant notation from her old record was for _______ previously recorded, her history of atrial fibrillation with rapid ventricular response and also it did appear that she had a non Q-wave event at that time. The Nitro paste and supplemental O2 resulted in 100% relief of her discomfort. EKG today shows a sinus mechanism. There is an isolated Q in lead three. Otherwise, it is unremarkable. Metabolic panel was normal. CBC reveals a mild leukocytosis at 35%. A D-dimer is indeterminate, greater than 0.5 less than 1.0. PT and PTT are within normal limits. Total CK is elevated at 427. MB 22.5. Index 5.3. Troponin is negative at less than 0.1. Chest x-ray reveals no acute cardiopulmonary disease, this film was pending final review with the radiologist.

At this time the patient is resting comfortably and is pain free. I have ordered a VQ for further evaluation for potential PEL. She has no risk factors for pulmonary embolism at this time nor is she hypoxic nor tachypneic. I did contact to Dr. ___ and reviewed that case. He recommends readmission, heparinization, nitrate, aspirin and further evaluation per Michigan Cardiovascular Institute.

ASSESSMENT AND PLAN: 1. Acute chest pain - resolved. 2. Probable
recurrent Q-wave event.

The patient is in stable condition. Courtesy bridging orders are
provided.

PLAN: As outlined above.

NEW COVENANT NORMALS



CVROSA: Normal review of systems of an adult
CVROSP: Normal review of systems for a child under 15 years of age
CVPEP: Normal physical exam ... pediatric
CVPEA: Normal physical exam ... adult
CVPEAT: Normal physical exam ... adult trauma

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