Notes
| Note Type | Source | Date | Author | View |
|---|---|---|---|---|
| Progress Note [pending] | UCLA Medical Center | 1/20/2017 | Dr. Lois Robertson | |
| Nursing Progress Report | UCLA Medical Center | 1/19/2017 | Nathaniel R. Miller | |
| Admission H&P | UCLA Medical Center | 1/19/2017 | Dr. Lois Robertson | |
| Ambulatory Clinic H&P | Veterans Affairs | 6/4/2011 | Dr. Shira W. Luciano |
Admission History and Physical 1/19/2017
Patient Name: Robert Elliot
Hospital Day: 1
Service: Medicine "C"
CC: "Flu"
HPI:
Robert Elliott is a 41-year-old Somoan-American male who comes to the emergency room today complaining of 'the flu' with intermittent fevers for 10-14 days, increasing fatigue and muscle aches.
He reports having had a sore throat about one month ago, but attributes it to a cold passed along from his wife and mother who had similar symptoms two weeks previously. Along with the sore throat, he felt feverish to the touch, tired and uninterested in eating. He also developed a cough productive of greenish sputum that was occasionally blood-streaked. These symptoms cleared after one week, leaving him with the low-grade intermittent fever and malaise over the past month. He awakened two days ago with a sore throat and slightly swollen ankle and today notes some tenderness in his left posterior thigh. Over the weekend he had an episode lasting about 6 hours where he had difficulty finding words. He took a nap for a few hours and it seemed to improve. His wife returned from a business trip and at her insistence he came to the emergency room where you are the rotating student.
ROS:
- HEENT: low grade headache, no blurred vision
- Neck: no complaints
- Cardiac: no chest pain, shortness of breath or palpitations. Reports murmur noted on previous VA employment physical.
- GI: no nausea, vomiting, or diarrhea. Continuing loss of appetite.
- GU: decreased urine output
- Skin: no rashes
- Lung: no prior respiratory illnesses. He has never been exposed to tuberculosis to his knowledge and had a negative PPD two years ago.
- Neuro: No weakness or numbness. Speech normal today.
PMH:
He has been in good health until the current complaints began one month ago. He has regular dental visits and recently had his teeth cleaned.
PSH:
None
Medications:
None
Allergies:
None
Social History:
He does not smoke and rarely drinks. He has never used recreational drugs. He works for the Veterans Administration in the financial office in a largely sedentary job. He has been married for the past 20 years and has one daughter who is in high school. He exercises regularly at a local gym.
Family History:
He is adopted and does not know his biological family history.
Physical Examination:
- BP: 130/80, P: 108, RR: 20, Temp: 101° F.
- General: ill appearing developed male complaining of fever and pain in his ankle.
- Skin: Warm and without cutaneous lesions.
- Eyes: Pupils equal, round and reactive to light.
- HEENT: Pharynx is normal. No lymphadenopathy. Jugular venous pressure is 4 cm of H2O. Carotid upstroke is brisk with normal duration. No bruits.
- Resp: Chest clear to auscultation and percussion.
- CV: Forceful, nondisplaced LV impulse, a soft mid-systolic murmur maximal at the base. No S3 or S4.
- Abd: Liver is normal in size to percussion. Possible spleen tip palpable in the LUQ. Non tender and normal bowel sounds.
- Extremities: Left ankle is slightly swollen from the high dorsum of the foot to the malleolus, erythematous and warm to the touch. Exquisitely tender. There is a 3x3 cm tender area on the left posterior thigh, without erythema or swelling.
- Nodes: two 1.5 cm L inguinal nodes.
- Pulses: symmetrical and strong throughout.
- Neuro: Normal
Labs/Studies:
| Value | Reference | |
|---|---|---|
| HGB | llg/dL | 12.3-16.3 g/dL |
| HCT | 33 % | 37.4-47.0 % |
| WBC | 21,000 mm3 | 3280-9290 mm3 |
| Polys | 90 % polys including some immature forms | |
| Routine Urinalysis (RUA) | 2+ protein, 14 RBCs, 1 WBC | |
| Electrolytes | Normal | |
| Creatinine | 1.5 mg/dL | 0.5-1.2 mg/dL |
| BUN | 26 mg/dL | 8-20 mg/dL |
| ALT | 93 U/L | 5-50 U/L |
| AST | 59 U/L | 15-50 U/L |
| Bilirubin | 2.8 mg/dL and indirect 1.9 mg/dL | |
| ESR | 108 mm/hr | |
| Albumin | 2.8 g/dL | 3.4-4.7 g/dL |
CXR: Chest x-ray shows no pulmonary infiltrates and a normal cardiac size.
ECG: An electrocardiogram is reported as showing sinus tachycardia with normal intervals and right bundle branch block.
Assessment & Plan:
41M with persistent fevers and evidence of peripheral septic embolic events (CNS, ankle, thigh) suggestive of infective endocarditis.
# Infective endocarditis:
- Blood cultures x2
- TTE with possible follow-up TEE
- Empiric antibiotic therapy with vancomycin pending culture results and sensitivities
- Obtain MRI brain, ankle, thigh to evaluate for septic emboli
- A fresh-voided A.M. urinalysis for microscopic exam
- Pharyngeal culture
- Rheumatoid factor
- ASO titer
# Anemia: possible hemolytic component
- LDH
Pre-Employment History and Physical 6/4/2011
Patient Name: Robert Elliot
Clinic Name: VA Clinic
CC:
Pre-Employment Physical Exam
HPI:
Robert Elliot is a 38 year-old male presenting for a pre-employment physical exam. He has no active complaints and states he is in good health. He does not currently take any prescription or over-the-counter medications, describes a varied diet with regular physical activity.
ROS:
Negative for major cardiovascular, pulmonary, GI, urinary, musculoskeletal or neurologic symptoms.
PMH:
None
PSH:
None
Medications:
None
Allergies:
None
Social History:
The patient is starting a position in the financial office of the VA. Denies tobacco or drug and drinks alcohol occasionally. He is married with one daughter. He denies feelings of depression.
Family History:
Adopted, biological parents unknown.
Physical Examination:
- VS: 128/80, P: 65, RR: 14, Temp: 98.0F.
- General: Well-appearing male in no acute distress.
- HEENT: Pupils equal, round and reactive to light, extraocular muscles intact, mucous membranes moist, oropharynx clear.
- Cardiovascular: Regular rate and rhythm, normal S1/S2, no S3/S4. Soft, II/VI systolic murmur best heard at right 2nd intercostal space, no radiation appreciated.
- Respiratory: Clear to auscultation bilaterally, no crackles or wheezing.
- Abdomen: Normoactive bowel sounds, non-distended, soft, non-tender without rebound or guarding.
- Extremities: Peripheral pulses equal in bilateral upper and lower extremities, no edema.
- Neuro: Alert and oriented to person, time and place. Cranial nerves II-XII intact. Gait normal.
Assessment & Plan:
40M with no significant medical history presenting for pre-employment physical examination. History and examination are unremarkable. There are no restrictions on starting employment. Recommend annual follow-up.