Report 3 Name: Carmen Kelly #040405 Dr Ali Ibrahami HISTORY AND PHYSICAL EXAMINATION 1 HISTORY 2 CHIEF COMPLAINT Vomiting, headache and blurred vision. 3 HISTORY OF PRESENT ILLNESS This is a 63-year-old Hispanic female who is an insulin-dependent diabetic who experienced the onset of headache, blurred vision, vomiting and hypotension this morning after she did not take her morning insulin. The patient was seen initially in the emergency room and found to have a blood pressure of 130/60 and a Dextrostix of greater than 250. The patient has a long-standing history of hypertension and said she was doing well until this morning when she developed the above complaints. She denies chest pain or diaphoresis. PAST HISTORY Habits: The patient does not smoke, drink or use recreational drugs. Medications: Regular insulin and nadolol (Corgard). Illnesses: No prior history of hepatitis, anemia, pulmonary, renal or gastrointestinal disease. Gravida 11, para 7. LNMP 10 years ago. Operations: None. ALLERGIES: NONE. PHYSICAL EXAMINATION GENERAL: This is an obese Hispanic female in no acute distress. She is alert, oriented and cooperative. VITAL SIGNS: Pulse: 46. Respiratory rate: 16. Temperature: 97.6 °F. NECK: No JVD. Supple without masses. CHEST: Clear to auscultation bilaterally. Heart: Bradycardia, regular rhythm, S1 and S2 present without abnormal heart sounds, murmurs. PMI difficult to assess. ABDOMEN: Bowel sounds normal, no organomegaly, abdomen protuberant. EXTREMITIES: No edema, cyanosis or clubbing. NEUROLOGIC: Grossly intact. IMPRESSION 1. First-degree heart block. This may be secondary to nadolol (Corgard). 2. Diabetes mellitus, type 2, requiring insulin adjustment. 3. Hypertension. PLAN 12 13 4 5 6 7 8 9 10 11 Fasting and 2-hour postprandial blood sugars. Regular insulin p.r.n. until blood sugar adjusted. Discontinue nadolol (Corgard). Begin clonidine 0.1 mg t.i.d. Stress thallium test, Holter 14 monitoring. ____________________________________ Ali Ibrahami, MD D: T: AI: Footnotes 1 Write out report titles in full. Add this section title per format. 3 Doctor dictates a colon following the heading. Omit the colon per format. 4 Doctor dictates a period after “insulin.” Use a hyphen instead per Rule 46. 5 Write out per Rule 63. 6 “Medication” dictated. Edit for plural format. 7 Doctor dictates brackets instead of parentheses. OK if typed with brackets, but parentheses are preferred. 8 Doctor dictates a period here in error. Edit to a comma per Rule 67. 9 When dictated, this sounds like “colpractic.” If you are unsure what the correct term should be, insert a flag. 10 When either “degrees” or “Fahrenheit” are dictated, add the other term to accompany to it. 11 Instead of commas separating the items in this sentence, periods would also be acceptable. 12 Rule 46 13 Edit to the correct heading for the H&P format. 14 Prefer to use periods to separate medications being discontinued from medications being started. 2